Name of Administrator: Address: Contact: Phone: Fax: Email: FEIN: Your Non-Resident* TPA license expires at midnight on December 31. To renew the license:
Please pay $200.00 upon submitting this form for the two-year renewal on or before the date listed above.
I attest that this license is in good standing in the state with a subsantially similar TPA law as that of Kansas in which you hold 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: 03/24/2023 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. Print Name of Officer: *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 contact the Kansas Insurance Department if you have any questions regarding this form or the renewal process.
