Company Name: Address:
Contact: Phone: Email:
FEIN:
Your Viatical License must be renewed from year to year by the anniversary date of the Provider's initial licensing. Your License 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 renewal payment of $500.00.
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 to the Department. This can be done either by email to kdoi.rf@ks.gov with "Viatical" in the subject line or by completing the online form available at Viatical Annual Form and clicking the “submit” button. Pursuant to K.S.A. 40-5013(b), failure to timely file the annual statement can subject you to a $500.00 penalty, plus $100 each week thereafter that the report is not provided.
Name of Officer: Title: Email: Phone: Date:
ATTESTATION:
Name of Person Submitting Application: Company: Title: Email: Phone:
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 knowingly providing false or fraudulent information or knowingly 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 license renewal application, revocation of License, or imposition of fines and penalties.
Please contact the Kansas Insurance Department Rate and Form Compliance Division if you have any questions regarding this form or the renewal process at kdoi.rf@ks.gov.
Date of Application: 04/24/2024
