Name of Administrator:
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:
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.