1. Applicant's Name:
Street Address:
City,State, Zip:
Phone Number:
Email:
In support of this Application for Certificate of Self-Insurance, the Applicant affirms the following:

• APPLICANT is one or more of the following: a public motor carrier of property, household goods, or passengers or a private motor carrier of property.
• 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 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 has sent any relevant bond information or other evidence of financial ability to pay judgments against the applicant to KDOI.RF@ks.gov
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
Filer:
Title:
Date: 11/21/2024