The following comprise the application necessary to obtain a Certificate of Registration as a prepaid legal or dental service plan in the State of Kansas. The completed application should be submitted to the Kansas Insurance Department for processing. Although the application is largely self-explanatory, a few specific instructions are listed below: No membership fees may be collected prior to issuance of the required Certificate of Registration. 1. A security deposit in the amount of $50,000 is required before issuance of a Certificate of Registration to any new prepaid service plan.i 2. For renewal applications, the deposit to be maintained depends on the amount of annual membership fees in this state. For example, when the annual membership fees in this state exceed $300,000, but are less than $750,000, the security amount is $75,000. If the annual membership fees in this state are more than $750,000, the security amount is $100,000. 3. Prepaid service plans submit copies of Certified Financial Audits prepared by a Certified Public Accountant, provider agreements, membership agreements, sales brochures, and other marketing material with this application. This allows the Kansas Insurance Department to determine how the plan is structured and what membership benefits are offered. 4. For questions or comments concerning the Prepaid Dental Service Plan application or the application process, please contact kdoi.rf@ks.gov. For questions or comments concerning the Prepaid Legal Service Plan application or the application process, please contact kdoi.rf@ks.gov. i. In lieu of the deposit of securities, a prepaid plan may submit a bond or irrevocable letter of credit in an amount and form acceptable to the Commissioner. Application for Certificate of Registration Prepaid Legal or Dental Service Plans Name of Applicant: Street Address: City, State, Zip: Phone: State of Domicile: Email Contact: APPLICANT hereby applies for a Certificate of Registration as a prepaid dental legal services plan pursuant to K.S.A. 40-4201 et seq. The following must be submitted with the Application: 1. An annual certified audit, prepared by a certified public accountant 2. Copies of membership and provider agreements 3. $100 fee paid online after submission of this application Please email documents to kid.addpc@ks.gov (Legal Plans) or kid.addah@ks.gov (Dental Plans). Sales Force The Prepaid Service Plan Representative List, disclosing the information requested about those individuals who solicit memberships in the plan, must be filled out below. Existing Plans must submit updates January 1 and July 1 each year. Financial Information Plan’s financial condition as of calendar year ending December 31, Capital/Surplus $ Annual Membership Fees in this state: Total amount collected from members nationwide for this calendar year: Deposit, Bond, or Irrevocable Letter of Credit to be submitted to or maintained with the Kansas Insurance Department $50,000 with application per K.S.A. 40-4211(a)(1). $75,000 with application per K.S.A. 40-4211(a)(3). $100,000 with application per K.S.A. 40-4211(a)(4). The Applicant's President, CEO, or other comparable official must make the following certification I certify that the above-named plan will abide by the following regulations: 1. The applicant plan shall not act as a prepaid plan without a written agreement between the plan and the provider and a written agreement between the plan and the member. 2. Such written agreements shall be retained as part of the official records of the plan for the duration of the agreements, and for five (5) years thereafter. 3. Such written agreements shall contain provisions that include the requirements of K.S.A.40-4201 through K.S.A. 40-4207. 4. Applicant plan has not had any previous applications for registration as a prepaid plan denied within the past five (5) years. 5. Applicant plan has not had any professional, vocational, or business license denied, suspended, revoked, or restricted by any public authority in this or any other state, nor has any such license been subjected to a monetary fine by any public authority, not has such license been withdrawn or surrendered to avoid disciplinary action. 6. Applicant plan has not had any judgment rendered against it in any court of any jurisdiction of the United States for its activities relating to the transaction of business as aprepaid service plan. 7. Applicant plan has not been declared insolvent or discharged from bankruptcy within the last five (5) years. 8. None of applicant plan's officers have been convicted in a criminal proceeding (excluding minor traffic violations) within the past ten (10) years. 9. Whenever a member utilizes the services of the prepaid service plan under the terms of a written contract required by K.S.A. 40-4202, the payment to the provider of any amount on behalf of the member by the prepaid service plan shall be deemed payment to the provider when received. 10.Applicant plan is the following type of entity (check only one): Individual Partnership Corporation Other Legal entity type The undersigned swears under oath they are the President, CEO, or comparable official of such plan, that they are authorized to execute and file this application, that they have read and fully understands the requirements of K.S.A. 40-4201 et seq. relating to such plan, and that the information contained in this application is true and accurate to the best of their knowledge. Name Title Signature of Applicant By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. PREPAID SERVICE PLAN REPRESENTATIVES LIST Name of Plan: Address: Telephone: Email Address: Authorized Signature Name and Title By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. The official records of the above Prepaid Service Plan indicate that the following representatives are authorized in Kansas as of Prepresentatives Names City, State, Zip
