Checklist: State of Kansas Purchasing Group Notice Form Completed Appointment of Attorney to Accept Service and Designation $250 Non-Refundable Notice Fee
1. List the Legal Name of the Purchasing Group: 2. FEIN: 3. List any other name(s) by which the Purchasing Group is known or may be doing business in this state or any other state: 4. Indicate the form of the organization (i.e., corporation, partnership, association) and the state in which organized. Organization: State: Address: 5. List the physical address, mailing address and email address of the administrative office of the Purchasing Group. Address: Mailing Address (if different): Email Contact: Main Administrative Contact: Name: Phone: Email: 6. The Purchasing Group intends to purchase the following lines and classifications of liability insurance: Aircraft Liability Excess Liability Owners & Contractors Protective Liability Railroad Protective Liability Auto Liability General Liability Pollution Liability Umbrella Liability Contractual Liability Liquor Liability Product Liability Teacher's Liability Employment Practices Liability Cyber Liability Professional Liability (Other than Med-Mal) Other. Describe: 7. The Purchasing Group intends to purchase the liability insurance described in Item #6 above from the following company or companies: Give full name of the company and its state of domicile. Name of Carrier: NAIC Cocode: State of Domicile: Admitted Non-Admitted Name of Carrier: NAIC Cocode: State of Domicile: Admitted Non-Admitted Name of Carrier: NAIC Cocode: State of Domicile: Admitted Non-Admitted Name of Carrier: NAIC Cocode: State of Domicile: Admitted Non-Admitted Name of Carrier: NAIC Cocode: State of Domicile: Admitted Non-Admitted 8. Does the Purchasing Group purchase liability insurance exclusively only for its group members and only to cover their similar or related liability exposure? Yes No 9. The Purchasing Group must be composed of members whose business or activities are similar or related with respect to the liability to which members are exposed by virtue of any related, similar or common business, trade, product, services, premises or operations. Please select the shared business areas from the list below. If "Other", provide a general description of the business or activities engaged by the Purchasing Group members: Accountants Bankruptcy Trustee/Receivers Dental HMOS Marina Operator Agricultural Commercial Vehicles Directors & Officers Home Inspectors Non-Profit Organizations Architects & Engineers Consultants Educational Institutions Hospital & Clinics Nursing Homes Attorneys Contractors Financial Institutions Insurance Professionals Office Professionals Asbestos/Environmental Daycare Funeral Directors Landowners & Developers Pest Control Aviation Dealers Extended Warranty Healthcare Practitioners Manufacturers & Distributors Physicians Property Owners & Managers Public Entities Publishing Real Estate Professionals Repossessors Restaurants & Hotels Retail Food Delivery Service Providers Sports & Recreation Stockbrokers Travel Trucking Wholesalers & Retailers Other. Describe: 10. The Purchasing Group has designated the Insurance Commissioner of this State to be its agent for the purpose for receiving service of legal documents or process by executing a document in substantially the same form as the sample document. Yes No 11. List the Purchasing Group Administrator 12. List the Purchasing Group's appointed agent(s): Name: NPN: Resident Non-Resident Name: NPN: Resident Non-Resident Name: NPN: Resident Non-Resident The Purchasing Group shall notify the Insurance Commissioner of any subsequent changes in any of the items included in this form. Yes No The undersigned hereby swear and affirm that the foregoing statements and information regarding (Name of Purchasing Group) are true and correct. Name: Position (ex. President, Director, Authorized Submitter): By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
