The undersigned Insurer hereby acknowledges its membership in the Workers Compensation Assigned Risk Pool and pledges its full participation and cooperation in carrying out the purposes of the Pool pursuant to K.S.A. 40-2109. Each member Insurer agrees to comply with the plan or plans of the Pool to apportion equitably the risks among insurers of applicants for insurance who are in good faith, entitled to but who are unable to procure through ordinary methods, workers compensation and/or employer's liability insurance


Date Signed


Name of Insurer

Address

BY:
Chief Executive Officer
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