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 Department of Insurance as required by K.S.A. 40-3813(d).

Signature of Officer:
Title:
Date:  11/21/2024

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 upload this form to the Attachments Warehouse for Kansas review.

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

This does NOT submit the form to SBS. The next screen will allow you to download the form and you must then upload the form to the Attachments Warehouse.