VIATICAL SETTLEMENT PROVIDER RENEWAL FORM












Your Viatical Certificate of Authority must be renewed from year to year by the anniversary date of Company's date of admittance. Your Certificate of Authority to do business in Kansas will expire if you fail to timely renew. K.S.A. 40-5003(c). When you click the submit button below, it will take you to a page to submit your payment. Your renewal is not considered complete until submission of this form and payment of the renewal fee (any any late payment penalty owed).

Please note, in addition to the renewal due annually by the anniversary date of Company's date of admittance, the Annual Statement is due annually by March 1st. K.S.A. 40-5006. The Annual Statement must be submitted electronically by email to kid.addah@ks.gov with "Viatical" in the subject line.


ATTESTATION:



By checking this box, I attest and affirm that I am authorized to submit this application on behalf of the applicant named herein, and that the information included is true, correct and complete to the best of my knowledge and belief. I understand that knowlingly providing false or fraudulent information or knowlingly making a material misrepresentation in connection with this application or any information or reports required under the Viatical Settlements Act of 2002, K.S.A. 40-5001 et seq., may result, inter alia, in the denial of the application, revocation of Certificate of Authority, or inposition of fines and penalites.

Please contact the Kansas Insurance Department if you have any questions regarding this form or the renewal process: kid.addah@ks.gov.

Date of Application: 08/10/2022