Pursuant to K.S.A. 40-4116

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.

5. List the physical address, mailing address and email address of the administrative office of the Purchasing Group.
Mailing Address (if different):
Email Contact:
Main Administrative Contact:

6. The Purchasing Group intends to purchase the following lines and classifications of liability insurance:

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.

8. Does the Purchasing Group purchase liability insurance exclusively only for its group members and only to cover their similar or related liability exposure?

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:


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.

11. List the Purchasing Group Administrator

12. List the Purchasing Group's appointed agent(s):



The Purchasing Group shall notify the Insurance Commissioner of any subsequent changes in any of the items included in this form.


The undersigned hereby swear and affirm that the foregoing statements and information regarding
(Name of Purchasing Group)
are true and correct.

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.