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:
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.