Form VL-1 "Application for Viatical Representative/Broker License" - Kansas

What Is Form VL-1?

This is a legal form that was released by the Kansas Insurance Department - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Kansas Insurance Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form VL-1 by clicking the link below or browse more documents and templates provided by the Kansas Insurance Department.

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Download Form VL-1 "Application for Viatical Representative/Broker License" - Kansas

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Mail to:
Kansas Insurance Department
Producer Licensing Division
1300 SW Arrowhead Road
Topeka, KS 66604
(785) 296-7862
APPLICATION FOR VIATICAL REPRESENTATIVE/BROKER LICENSE
Check:
BROKER
REPRESENTATIVE
Name in Full ________________________________________________________________ Date of Birth ____________________
(Last
(First)
(Middle)
Other Business Name or Alias __________________________________________________________________________________
Social Security No. ____________________ Home Telephone ____________________ Bus. Telephone ______________________
Resident Address _____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Business Address _____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Email Address _______________________________________________________________________________________________
1. With what viatical companies and in what capacity will you be affiliated?
_________________________________________________________________________________________________________
(Name of Company)
Located at what address? ____________________________________________________________________________________
2. Do you intend to purchase policies from viators? (Yes) ______ (No)______
Do you intend to sell viaticated policies to investors? (Yes) ______ (No) ______ If you intend to sell viaticated policies, you
must also be licensed to sell securities.
3. Are you now or have you ever been licensed in Kansas or any other state to write securities? (Yes) ______ (No) ______
4. Have you ever been refused a license or has your license ever been suspended or revoked by the Kansas Insurance Department, the
Kansas Securities Commissioner, or any other insurance/securities department? (Yes) ______ (No) ______ If yes, by what
department and when? ______________________________________________________________________________________
_________________________________________________________________________________________________________
5. Has any federal or state regulatory authority or self-regulatory authority ever denied, revoked, or suspended your registration or
license or issued an order disciplining you or restricted your activities? (Yes) ______ (No) ______ If yes, explain the details and
dates. ___________________________________________________________________________________________________
_________________________________________________________________________________________________________
6. Have you ever been convicted of or pleaded guilty or nolo contendere to any misdemeanor or felony? (Yes) ______ (No) ______
Use Guidelines for answering this question. If yes, explain the details and dates. Use supplemental sheet if necessary. _________
_________________________________________________________________________________________________________
I certify I have read this application and understand that any omissions or false answers may result in a refusal by the
commissioner of insurance to issue to me a viatical license. I authorize the release to the Kansas Insurance Department of any
information relative to any of my convictions contained in the files of any law enforcement or investigative agency. Further, I
authorize this release without prejudice or liability on the part of any law enforcement or investigative agency or the Kansas
Insurance Department. I affirm that all answers on this application or any supplementary pages attached have been
completed by me personally and to the best of my knowledge are true and complete. On the basis thereof I hereby make
application for a license to act as a viatical representative/broker in accordance with the Insurance Laws of Kansas.
___________________________________________________________________________
_________________________________________________
Original Applicant Signature
Month
Day
Year
___________________________________________________________________________
Full Legal Name (Printed or Typed)
If the answers to any of the questions contained in this application require more space, use separate sheets of paper. Read carefully the information on the reverse side.
The Social Security number of the individual listed hereon is requested pursuant to K.S.A. 74-139, but applicants are not required to provide it. If included, the Social
Security number will be used for identification purposes only.
FEE DUE $100
VL-1 (11/19)
Checked By:
Date Issued:
Mail to:
Kansas Insurance Department
Producer Licensing Division
1300 SW Arrowhead Road
Topeka, KS 66604
(785) 296-7862
APPLICATION FOR VIATICAL REPRESENTATIVE/BROKER LICENSE
Check:
BROKER
REPRESENTATIVE
Name in Full ________________________________________________________________ Date of Birth ____________________
(Last
(First)
(Middle)
Other Business Name or Alias __________________________________________________________________________________
Social Security No. ____________________ Home Telephone ____________________ Bus. Telephone ______________________
Resident Address _____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Business Address _____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Email Address _______________________________________________________________________________________________
1. With what viatical companies and in what capacity will you be affiliated?
_________________________________________________________________________________________________________
(Name of Company)
Located at what address? ____________________________________________________________________________________
2. Do you intend to purchase policies from viators? (Yes) ______ (No)______
Do you intend to sell viaticated policies to investors? (Yes) ______ (No) ______ If you intend to sell viaticated policies, you
must also be licensed to sell securities.
3. Are you now or have you ever been licensed in Kansas or any other state to write securities? (Yes) ______ (No) ______
4. Have you ever been refused a license or has your license ever been suspended or revoked by the Kansas Insurance Department, the
Kansas Securities Commissioner, or any other insurance/securities department? (Yes) ______ (No) ______ If yes, by what
department and when? ______________________________________________________________________________________
_________________________________________________________________________________________________________
5. Has any federal or state regulatory authority or self-regulatory authority ever denied, revoked, or suspended your registration or
license or issued an order disciplining you or restricted your activities? (Yes) ______ (No) ______ If yes, explain the details and
dates. ___________________________________________________________________________________________________
_________________________________________________________________________________________________________
6. Have you ever been convicted of or pleaded guilty or nolo contendere to any misdemeanor or felony? (Yes) ______ (No) ______
Use Guidelines for answering this question. If yes, explain the details and dates. Use supplemental sheet if necessary. _________
_________________________________________________________________________________________________________
I certify I have read this application and understand that any omissions or false answers may result in a refusal by the
commissioner of insurance to issue to me a viatical license. I authorize the release to the Kansas Insurance Department of any
information relative to any of my convictions contained in the files of any law enforcement or investigative agency. Further, I
authorize this release without prejudice or liability on the part of any law enforcement or investigative agency or the Kansas
Insurance Department. I affirm that all answers on this application or any supplementary pages attached have been
completed by me personally and to the best of my knowledge are true and complete. On the basis thereof I hereby make
application for a license to act as a viatical representative/broker in accordance with the Insurance Laws of Kansas.
___________________________________________________________________________
_________________________________________________
Original Applicant Signature
Month
Day
Year
___________________________________________________________________________
Full Legal Name (Printed or Typed)
If the answers to any of the questions contained in this application require more space, use separate sheets of paper. Read carefully the information on the reverse side.
The Social Security number of the individual listed hereon is requested pursuant to K.S.A. 74-139, but applicants are not required to provide it. If included, the Social
Security number will be used for identification purposes only.
FEE DUE $100
VL-1 (11/19)
Checked By:
Date Issued: