"Viatical Company Appointment/Cancellation Form" - Kansas

Viatical Company Appointment/Cancellation Form is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

Form Details:

  • Released on November 1, 2019;
  • 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.

ADVERTISEMENT
ADVERTISEMENT

Download "Viatical Company Appointment/Cancellation Form" - Kansas

Download PDF

Fill PDF online

Rate (4.4 / 5) 8 votes
KANSAS INSURANCE DEPARTMENT
VIATICAL COMPANY APPOINTMENT/CANCELLATION FORM
Please enter the company name and address in the space below.
NAIC#
________________________
Check One Item Below
APPOINT
CANCEL
The company is appointing for all qualifications for which the appointee is properly licensed in this state. The company is
responsible to ensure the appointee only sells products for which he/she is properly licensed.
The company is responsible for notifying the viatical representative/broker of termination. If the appointment is canceled for
cause, provide a detailed letter of explanation. If the appointment is canceled because the appointee has moved, provide the
new address. If the appointment is canceled because the appointee is deceased, provide the date of death.
I HEREBY APPOINT AND CERTIFY THAT I HAVE INVESTIGATED THE QUALIFICATIONS OF THIS APPOINTEE
AND THAT THE APPOINTEE MEETS ALL REQUIREMENTS UNDER THIS STATE’S INSURANCE STATUTES AND
REGULATIONS. IF THIS IS A CANCELLATION, I CERTIFY THAT THIS CANCELLATION COMPLIES WITH
STATE STATUTES AND REGULATIONS.
BY: ________________________________________________
__________________________________________________
Signature
Date
________________________________________________
__________________________________________________
Phone/Extension (For Questions About The Information On This Form)
Typed Name and Title
APPOINTEE SSN
APPOINTEE NAME
APPOINTEE RESIDENCE OR
EFFECTIVE
OR NPN
BUSINESS ADDRESS
DATE
Return to:
Producer Licensing Division
1300 SW Arrowhead Road
Topeka, KS 66604
(785) 296-7860
Rev. 11/19
This Form May Be Duplicated
KANSAS INSURANCE DEPARTMENT
VIATICAL COMPANY APPOINTMENT/CANCELLATION FORM
Please enter the company name and address in the space below.
NAIC#
________________________
Check One Item Below
APPOINT
CANCEL
The company is appointing for all qualifications for which the appointee is properly licensed in this state. The company is
responsible to ensure the appointee only sells products for which he/she is properly licensed.
The company is responsible for notifying the viatical representative/broker of termination. If the appointment is canceled for
cause, provide a detailed letter of explanation. If the appointment is canceled because the appointee has moved, provide the
new address. If the appointment is canceled because the appointee is deceased, provide the date of death.
I HEREBY APPOINT AND CERTIFY THAT I HAVE INVESTIGATED THE QUALIFICATIONS OF THIS APPOINTEE
AND THAT THE APPOINTEE MEETS ALL REQUIREMENTS UNDER THIS STATE’S INSURANCE STATUTES AND
REGULATIONS. IF THIS IS A CANCELLATION, I CERTIFY THAT THIS CANCELLATION COMPLIES WITH
STATE STATUTES AND REGULATIONS.
BY: ________________________________________________
__________________________________________________
Signature
Date
________________________________________________
__________________________________________________
Phone/Extension (For Questions About The Information On This Form)
Typed Name and Title
APPOINTEE SSN
APPOINTEE NAME
APPOINTEE RESIDENCE OR
EFFECTIVE
OR NPN
BUSINESS ADDRESS
DATE
Return to:
Producer Licensing Division
1300 SW Arrowhead Road
Topeka, KS 66604
(785) 296-7860
Rev. 11/19
This Form May Be Duplicated