KNOW ALL MEN BY THESE PRESENTS, THAT
of , as principal, and of , as surety, are held and firmly bound to the Commissioner of Insurance of the State of Kansas, and his successors, and on behalf of all person whose application for Kansas membership in the above-name principal has been accepted by such principal or his representative, in the penal sum of for payment of which, well and truly to be made, we do jointly and severally bind ourselves, our heirs, personal representatives, successors and assigns for the protection of Kansas Members in this plan.

The above-named principal has made application to the Commissioner of Insurance for a Certificate of Registration to operate a prepaid service plan in Kansas as provided by K.S.A. 40- 4201, et seq. This obligation shall be for the benefit of any person or persons sustaining an actionable injury due to the failure of the prepaid service plan to faithfully perform its obligations to its members or those providers with whom it has contracted and shall be subject to action thereon by andy such person of persons for such purposes in the event of insolvency or impariment of the prepaid service plan.

Now, therefore, if such Certificate of Registration is issued, and if the above named principal, his agents, servants and employees shall comply with the prepaid service plan and shall faithfully furnish and render any and all of the prepaid services sold or offered for sale by it, and shall pay any fines, fees, or penalties imposed upon it pursuant to K.S.A. 40-4201, et seq., then this obligation shall be void; but, otherwise to remain in full force and effect until cancelled pursuant to the provisions of K.S.A. 40-4211(e).

Witness our hands this day of year of

Principal

Surety

By:
(Attorney-in-fact)

Countersigned in Kansas
By
Title
Address
(This bond must be accompanied by a Power of Attorney from the Surety to the Attorney-In Fact specifying his authority).