To become relisted or initially listed as an surplus lines carrier in the State of Kansas, please complete the following:

Name of Company:

Company NAIC:

There is a $200.00 fee upon submission of this application.

If you are applying to relist, the fee is due by May 1 of every year. Please note that if you are an initial applicant company applying before May 1, you will not have to repay the fee until the following year.

By checking this box, I attest that the above-listed company has a capital surplus at or in excess of 4.5 million dollars on this year’s company annual statement.

Initial Applicants Only. A copy of your annual statement must be emailed to kid.addpc@ks.gov

Name of person completing application:
Phone:

Email: