"Risk Retention Group - Notice and Registration" - Kansas

Risk Retention Group - Notice and Registration is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

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STATE OF KANSAS
DEPARTMENT OF INSURANCE
RISK RETENTION GROUP - NOTICE AND REGISTRATION
K.S.A. 40-4101 et seq.
(All information should be typed)
1. Name of the Risk Retention Group as it appears on its Certificate of Authority:
_____________________________________________________________________________
Principal Place of Business_______________________________________________________
Mailing Address_______________________________________________________________
NAIC Number__________________
Group’s Federal Id Number____________________
Name, phone number, and email address of person to be contacted for information regarding this
application:
_____________________________________________________________________________
2. List any other name(s) by which the Risk Retention Group is known or may be doing business in
this State or any other state (if none, answer none):_____________________________________
3. The Risk Retention Group is a corporation or other limited liability association whose primary
activity consists of assuming and spreading all, or any portion, of the liability exposure of its
members.
4. The Risk Retention Group is organized for the primary purpose of conducting the activity
described under item #3 above.
5. The Risk Retention Group is chartered and licensed as a liability insurance company under the
laws of the State of __________________, and is authorized to engage in the following lines
and/or classifications of insurance under the laws of its chartering State (List):
_____________________________________________________________________________
_____________________________________________________________________________
6. The Risk Retention Group does not exclude any person from membership in the Group solely to
provide for members of the Group a competitive advantage over such a person.
7. Ownership of the Risk Retention Group consists of one or the other of the following (check one):
a.) _____ the owners of the Group are the only persons who comprise the membership of the
Group and who are provided insurance by the Group.
b.) _____ the sole owner of the Group is:
_____________________________________________________________________________
(Name and Address of Organization)
8. The Risk Retention Group members are engaged in businesses or activities similar or related
with respect to the liability to which such members are exposed by virtue of related, similar or
common business, trade, product, services, premises or operations. Give a general description of
businesses or activities engaged in by the Group’s members.
_____________________________________________________________________________
_____________________________________________________________________________
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STATE OF KANSAS
DEPARTMENT OF INSURANCE
RISK RETENTION GROUP - NOTICE AND REGISTRATION
K.S.A. 40-4101 et seq.
(All information should be typed)
1. Name of the Risk Retention Group as it appears on its Certificate of Authority:
_____________________________________________________________________________
Principal Place of Business_______________________________________________________
Mailing Address_______________________________________________________________
NAIC Number__________________
Group’s Federal Id Number____________________
Name, phone number, and email address of person to be contacted for information regarding this
application:
_____________________________________________________________________________
2. List any other name(s) by which the Risk Retention Group is known or may be doing business in
this State or any other state (if none, answer none):_____________________________________
3. The Risk Retention Group is a corporation or other limited liability association whose primary
activity consists of assuming and spreading all, or any portion, of the liability exposure of its
members.
4. The Risk Retention Group is organized for the primary purpose of conducting the activity
described under item #3 above.
5. The Risk Retention Group is chartered and licensed as a liability insurance company under the
laws of the State of __________________, and is authorized to engage in the following lines
and/or classifications of insurance under the laws of its chartering State (List):
_____________________________________________________________________________
_____________________________________________________________________________
6. The Risk Retention Group does not exclude any person from membership in the Group solely to
provide for members of the Group a competitive advantage over such a person.
7. Ownership of the Risk Retention Group consists of one or the other of the following (check one):
a.) _____ the owners of the Group are the only persons who comprise the membership of the
Group and who are provided insurance by the Group.
b.) _____ the sole owner of the Group is:
_____________________________________________________________________________
(Name and Address of Organization)
8. The Risk Retention Group members are engaged in businesses or activities similar or related
with respect to the liability to which such members are exposed by virtue of related, similar or
common business, trade, product, services, premises or operations. Give a general description of
businesses or activities engaged in by the Group’s members.
_____________________________________________________________________________
_____________________________________________________________________________
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9. The activities of the Risk Retention Group do not include the provision of insurance other than:
(a) liability insurance for assuming and spreading all or any portion of the similar or related
liability exposure of its Group members; and (b) reinsurance with respect to the similar or related
liability exposure of another Risk Retention Group (or a member of such other Risk Retention
Group) engaged in business or activities which qualify such other Risk Retention Group (or
member) under item #8 above or membership in this group.
10. (a) List the name, social security number (SS#) and address of each officer and director of the
Risk Retention Group: (attach additional pages, if necessary):
Name
SS#
Position with RRG
Address
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(b) Identify and give the telephone number of the officer or director of the Risk Retention Group
who can be contacted for any information regarding the management of the insurance activities
of the Group:
Name: ________________________________Position Held____________________________
Telephone Number: _____________________E-mail Address___________________________
11. List the name, address, telephone number and Federal Employer Identification Number (FEIN)
of the company responsible for managing the insurance operations of the Risk Retention Group
and the contact person at the company (if none, answer none):
Name
FEIN
Address
Telephone #
_____________________________________________________________________________
Contact Person: ________________________
Telephone # ___________________________E-mail Address___________________________
12. List the name(s), SS#(s) and address (es) of the licensed insurance agent(s) or broker(s)
responsible for marketing the Risk Retention Group’s insurance policies and the state(s) in which
they are licensed, including Kansas: (If none, answer none. Attach additional pages, if necessary)
Name
SS#
Address
State(s)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
13. The Risk Retention Group will comply with the unfair claim settlement practices laws of Kansas.
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14. The Risk Retention Group will pay, on a non-discriminatory basis, applicable premium and other
taxes, which are levied on such Group under the laws of Kansas.
15. The Risk Retention Group has designated the Kansas Insurance Commissioner to be its agent
solely for the purpose of receiving service of legal documents or process. Attach the completed
NAIC Form 12, “Consent to Service of Process Form” (Note: must be signed by both the
president and secretary of the RRG.)
16. The Risk Retention Group will submit to examination by the Kansas Insurance Commissioner to
determine the Group’s financial condition, if:
 The Insurance Commissioner [Director, Superintendent] of the Group’s chartering State
has not begun or does not initiate an examination within 60 days after a request by the
Kansas Insurance Commissioner.
17. The Risk Retention Group will comply with a lawful order issued in a delinquency proceeding
commenced by the Kansas Insurance Commissioner upon a finding of financial impairment, or
in a voluntary dissolution proceeding.
18. The Risk Retention Group will comply with the laws of Kansas concerning deceptive, false or
fraudulent acts or practices, including any injunctions regarding such conduct obtained from a
court of competent jurisdiction.
19. The Risk Retention Group will comply with an injunction issued by a court of competent
jurisdiction upon petition by the Kansas Insurance Commissioner alleging that the Group is in
hazardous financial condition or is financially impaired.
20. The Risk Retention Group will provide the following notice, in at least 10-point type, in any
insurance policy issued by the Group:
NOTICE:
This policy is issued by your risk retention group. Your risk retention group may not be
subject to all of the insurance laws and regulations of your State. State insurance
insolvency guaranty funds are not available for your risk retention group.
21. The Risk Retention Group has submitted to the Kansas Insurance Commissioner as part of this
filing and before it has offered any insurance in this State, a copy of the plan of operation or
feasibility study, which is, has filed with the Insurance Commissioner [Director, Superintendent]
of its chartering State. This plan or study includes the name of the State in which the Group is
chartered, as well as the Group’s principal place of business, and such plan or study further
includes the coverage’s, deductibles, coverage limits, rates, and rating classification systems for
each line of insurance the Group intends to offer. The Group will promptly submit to the Kansas
Insurance Commissioner any revisions of such plan or study to reflect any changes to the plan if
the Group intends to offer any additional lines of liability insurance, including any change in the
designation of the State in which it is chartered.
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22. The Risk Retention Group will submit a copy of its annual financial statement submitted to its
chartering State, to the Insurance Commissioner of this State, by March 1
of each year. The
st
annual financial statement will be certified by an independent public accountant and include a
statement of opinion on loss and loss adjustment expense reserves made by a member of the
American Academy of Actuaries or a qualified loss reserve specialist. The certification and
statement of opinion on loss and loss adjustment expense reserves will be submitted to the
Kansas Insurance Commissioner by the date it is required to be submitted to its chartering state.
23. The Risk Retention Group will not solicit or sell insurance to any person in Kansas who is not
eligible for membership in the Group.
24. The Risk Retention Group will not solicit or sell insurance in Kansas, or otherwise operate in this
State, if the Group is in hazardous financial condition or is financially impaired.
25. The Risk Retention Group will not issue any insurance policy in this State, which provides
coverage prohibited generally by statute of Kansas or declared unlawful by the highest court of
this State whose law applies to such policy.
26. The Risk Retention Group is not directly or indirectly owned by, or have members that are, an
insurance company.
27. The Risk Retention Group has submitted a notification fee of $250.00, payable to the Kansas
Insurance Commissioner.
28. The Risk Retention Group will comply with all other applicable state laws.
29. The Risk Retention Group will notify the Kansas Insurance Commissioner as to any subsequent
changes in any of the items included in this form.
The undersigned hereby swear and affirm that the foregoing statements and information regarding
this Risk Retention Group are true and correct:
____________________________________________________________________
President or Chief Executive Officer of the Risk Retention Group (sign & print name)
____________________________________________________________________
Secretary of the Risk Retention Group (sign & print name)
State of ____________________________)
County of __________________________)
Sworn before me this __________ day of __________________________, 20___.
____________________________________________
Notary Public
____________________________________________
My Commission Expires
(Seal)
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