Name of Title Agent/Agency:

Under the Unique and Unusual Rule, the following individual risk filing must be submitted to the Kansas Insurance Department. See Bulletin 1989-31.

AGENCY IDENTIFICATION INFORMATION:

Name of Insured/Proposed Insured:

Property Location:

Policy/Commitment/File Number:

Charge/Rate:

Filed charge/Rate:

Reason for Deviation from Filed Charge:

By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Signature:
Email:
Date: 04/20/2024