"Change in Registration for Purchasing Groups" - Kansas

Change in Registration for Purchasing Groups is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

Form Details:

  • 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 fillable version of the form by clicking the link below or browse more documents and templates provided by the Kansas Insurance Department.

ADVERTISEMENT
ADVERTISEMENT

Download "Change in Registration for Purchasing Groups" - Kansas

Download PDF

Fill PDF online

Rate (4.7 / 5) 11 votes
Kansas Insurance Department
Change in Registration for Purchasing Groups
420 SW 9th St
Topeka KS 66612
Due within 10 days of effective date of change.
Name of Purchasing Group, Group contact name and email address:
Group's Federal Employer I.D. Number
Check box(es) to show which
Effective date
Purchasing Group registration
New information
of change
information changed:
Purchasing Group Name
Address
Phone Number
Email Address
Delete Current Insurer
List company name & NAIC
number
Add New Company
List company name & NAIC
number
Delete Agent
List Agent's name, address, phone
number & email address
Change Agent
List Agent's name, address, phone
number & email address
Delete state
Change Purchasing Group
Officer
Change Purchasing Group
Contact
List name, address, phone number
& email address
Other (describe)
Attach additional sheets if needed.
Officer Certification:
I certify that the information in this report and any attachments included with it is complete and correct.
Signature of officer of the Purchasing Group
Date signed
Name, email & phone number of person to contact regarding this report
Officer Name and Title (please type or print)
Risk Retention Act of 1986, 3903 (d)(2) requires submission of any Purchasing Group
Our web address is: www.ksinsurance.org
registration information changes. Failure to file properly may result in a compliance
Questions Contact: Marcia Kramer. 785.291.3454
action against the purchasing group.
marcia.kramer@ks.gov
Kansas Insurance Department
Change in Registration for Purchasing Groups
420 SW 9th St
Topeka KS 66612
Due within 10 days of effective date of change.
Name of Purchasing Group, Group contact name and email address:
Group's Federal Employer I.D. Number
Check box(es) to show which
Effective date
Purchasing Group registration
New information
of change
information changed:
Purchasing Group Name
Address
Phone Number
Email Address
Delete Current Insurer
List company name & NAIC
number
Add New Company
List company name & NAIC
number
Delete Agent
List Agent's name, address, phone
number & email address
Change Agent
List Agent's name, address, phone
number & email address
Delete state
Change Purchasing Group
Officer
Change Purchasing Group
Contact
List name, address, phone number
& email address
Other (describe)
Attach additional sheets if needed.
Officer Certification:
I certify that the information in this report and any attachments included with it is complete and correct.
Signature of officer of the Purchasing Group
Date signed
Name, email & phone number of person to contact regarding this report
Officer Name and Title (please type or print)
Risk Retention Act of 1986, 3903 (d)(2) requires submission of any Purchasing Group
Our web address is: www.ksinsurance.org
registration information changes. Failure to file properly may result in a compliance
Questions Contact: Marcia Kramer. 785.291.3454
action against the purchasing group.
marcia.kramer@ks.gov
INSTRUCTIONS FOR COMPLETING FORM:
Name of the Purchasing Group, Group contact name and email address
The name of the purchasing group should be shown exactly as it was on the original registration form, DO NOT USE ABBREVIATIONS. ALL
SUBMISSIONS MUST COMPLETE THIS SECTION.
Purchasing Group Name, Address, Phone Number & Email Address
Click appropriate box of item that is changing. In the New Information section, please include email address, as all correspondence will now
be done electronically.
Delete Current Insurer
If deleting existing company, click box. In the New Information section, please include the company's name and NAIC number.
Add New Company
If adding a new insurance company, click box. In the New Information section, please include the company's name and NAIC number.
Delete Agent
If deleting an agent. click this box. In the New Information section, please provide name, address, phone number and license number.
Change Agent
If adding a new agent, click this box. In the New Information section, please provide name, address, phone number, email address and
license number.
Delete State
If withdrawing from a state that group is presently registered in, click this box.
Change Purchasing Group Officer
If the group is changing an officer, click this box. In the New Information section, provide new officers name, address and new position.
Change Purchasing Group Contact
If group's contact is to be changed, click this box. In the New Information section, provide new contact's name, address, phone number
and email address.
Other (Describe)
For all other changes, click this box. In the New Information section, provide necessary information including name, address, phone number
and email address.
Page of 2