"Statement of Insured" - Kansas

Statement of Insured is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

Form Details:

  • Released on November 1, 2016;
  • The latest edition currently provided by the Kansas Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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STATEMENT OF INSURED
THIS FORM MUST BE COMPLETED IN DETAIL FOR EACH NEW RISK PLACED
AND FOR RENEWAL OF PREVIOUSLY PLACED RISKS. A COPY OF THIS
STATEMENT MUST BE PROVIDED TO THE INSURED AND MAINTAINED IN
AGENT’S FILES.
INSURED:_
COVERAGE TYPE:
POLICY PERIOD: _/
/
TO
_/
/
Check one of the options below:
EXEMPT COMMERCIAL PURCHASER (defined in K.S.A. 40-246i)
As required by K.S.A. 40-246b, this will certify that I, the undersigned, have requested insurance coverage to be
placed on my behalf with a company that is non-admitted or licensed to transact business in the State of Kansas. I
understand, that as an exempt commercial purchaser, contrary to K.S.A. 40-246b, a diligent search of the admitted
market is not required to place this coverage with a company that is non-admitted or licensed to transact business in
this state. I further understand that such insurance may or may not be available from the admitted market that may
provide greater protection with more regulatory oversight.
ALL OTHER INSUREDS (Other than exempt commercial purchasers)
As required by K.S.A. 40-246b, this will certify that I, the undersigned, have requested insurance coverage to be
placed on my behalf with a company that is non-admitted or licensed to transact business in the State of Kansas. I
understand that in accordance with K.S.A. 40-246b, that mere rate differential shall not be grounds for placing a
particular risk with a non-admitted company when an admitted company would accept such risk at a different rate.
It is further acknowledged that the following information regarding placement of insurance with a non-admitted
company, has been provided by the licensed excess lines agent:
1. The insurance coverage requested will be provided by an insurance company that is non-admitted or licensed to
transact business in the State of Kansas, and whose name appears on the list of non-admitted companies
maintained by the Commissioner of Insurance. The non-admitted insurers’ financial condition, policy forms,
rates and trade practices are not subject to review or the jurisdiction of the Commissioner of Insurance.
2. There shall be no liability on the part of, and no cause of action of any nature shall arise against the
Commissioner of Insurance, employees thereof, or the State of Kansas because the name of an insurance
company appears or does not appear on the list of non-admitted companies maintained by the Commissioner of
Insurance.
3. The policies or contracts of insurance issued by a non-admitted insurance company do not come under the
protection afforded by the Kansas Insurance Guaranty Association Act (K.S.A. 40-2901, et seq.).
4. If the insurance company affording coverage is subsequently determined to be insolvent, the licensed excess
lines agent placing such business with a company nonadmitted to transact business in Kansas is, by giving you
the information contained herein, relieved of any responsibility to the insured as it relates to such solvency.
5.
Each licensed agent shall collect and pay to the commissioner a tax of 6% on the total gross premiums charged,
less any return premiums, for surplus lines insurance transacted by the licensee pursuant to the license for insureds
whose home state is this state. (K.S.A. 40-246c)
Insured
Agent
Date
I was unavailable or otherwise unable to sign this statement prior to the effective date of coverage.
SOI (11/16)
STATEMENT OF INSURED
THIS FORM MUST BE COMPLETED IN DETAIL FOR EACH NEW RISK PLACED
AND FOR RENEWAL OF PREVIOUSLY PLACED RISKS. A COPY OF THIS
STATEMENT MUST BE PROVIDED TO THE INSURED AND MAINTAINED IN
AGENT’S FILES.
INSURED:_
COVERAGE TYPE:
POLICY PERIOD: _/
/
TO
_/
/
Check one of the options below:
EXEMPT COMMERCIAL PURCHASER (defined in K.S.A. 40-246i)
As required by K.S.A. 40-246b, this will certify that I, the undersigned, have requested insurance coverage to be
placed on my behalf with a company that is non-admitted or licensed to transact business in the State of Kansas. I
understand, that as an exempt commercial purchaser, contrary to K.S.A. 40-246b, a diligent search of the admitted
market is not required to place this coverage with a company that is non-admitted or licensed to transact business in
this state. I further understand that such insurance may or may not be available from the admitted market that may
provide greater protection with more regulatory oversight.
ALL OTHER INSUREDS (Other than exempt commercial purchasers)
As required by K.S.A. 40-246b, this will certify that I, the undersigned, have requested insurance coverage to be
placed on my behalf with a company that is non-admitted or licensed to transact business in the State of Kansas. I
understand that in accordance with K.S.A. 40-246b, that mere rate differential shall not be grounds for placing a
particular risk with a non-admitted company when an admitted company would accept such risk at a different rate.
It is further acknowledged that the following information regarding placement of insurance with a non-admitted
company, has been provided by the licensed excess lines agent:
1. The insurance coverage requested will be provided by an insurance company that is non-admitted or licensed to
transact business in the State of Kansas, and whose name appears on the list of non-admitted companies
maintained by the Commissioner of Insurance. The non-admitted insurers’ financial condition, policy forms,
rates and trade practices are not subject to review or the jurisdiction of the Commissioner of Insurance.
2. There shall be no liability on the part of, and no cause of action of any nature shall arise against the
Commissioner of Insurance, employees thereof, or the State of Kansas because the name of an insurance
company appears or does not appear on the list of non-admitted companies maintained by the Commissioner of
Insurance.
3. The policies or contracts of insurance issued by a non-admitted insurance company do not come under the
protection afforded by the Kansas Insurance Guaranty Association Act (K.S.A. 40-2901, et seq.).
4. If the insurance company affording coverage is subsequently determined to be insolvent, the licensed excess
lines agent placing such business with a company nonadmitted to transact business in Kansas is, by giving you
the information contained herein, relieved of any responsibility to the insured as it relates to such solvency.
5.
Each licensed agent shall collect and pay to the commissioner a tax of 6% on the total gross premiums charged,
less any return premiums, for surplus lines insurance transacted by the licensee pursuant to the license for insureds
whose home state is this state. (K.S.A. 40-246c)
Insured
Agent
Date
I was unavailable or otherwise unable to sign this statement prior to the effective date of coverage.
SOI (11/16)