Applicant's Name: Street Address: City, State, Zip: Phone Number: Email Address: In support of this Application for Certificate of Self-Insurance, the Applicant affirms the following:
•APPLICANT has on this date more than twenty-five (25) vehicles registered and will continue to have registered more than twenty-five (25) vehicles.
•APPLICANT has the responsibility to immediately notify the Kansas Insurance Department at any time the total number of registered vehicles is less than this requirement.
•APPLICANT is possessed and will continue to be possessed of the ability to pay any liability imposed by law against APPLICANT arising out of the ownership, operation, maintenance, or use of any motor vehicle registered in its name.
•APPLICANT is a participant in the Kansas Automobile Assigned Claims Plan, as requiredby K.S.A. 40-3116.
By submitting this application, the undersigned represents that the information provided herein is accurate and complete, that they possess sufficient authority to submit this application on behalf of the Applicant, and that they will notify the Kanas Insurance Department with any changes in the Applicant’s status affecting qualification to possess a Certificate of Self-Insurance and any changes to the Applicant’s contact information.
Name of Individual Submitting Applicant: Title: Date: 03/24/2023
