Name of Adminstrator:
Address:
City, State, Zip:

I attest that Administrator’s license is in good standing in a reciprocal state with a substantially similar TPA law as that of Kansas in which Administrator holds a resident license. In addition, I attest that all administrative actions and criminal prosecutions have been timely reported to the Kansas Insurance Department as required by K.S.A. 40-3813(d).

Signature of Officer:
Title:
Date:  04/29/2024

Only non-resident administrators are required to renew on a biennial basis. A Kansas Home State license is perpetual unless suspended, surrendered, or revoked. Please download this form to the Attachments Warehouse for Kansas review.

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

*By typing your name above, you are signing this document electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.