"Prepaid Legal of Dental Service Plans Application for New or Renewal Certificate of Registration" - Kansas

Prepaid Legal of Dental Service Plans Application for New or Renewal Certificate of Registration 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 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 "Prepaid Legal of Dental Service Plans Application for New or Renewal Certificate of Registration" - Kansas

Download PDF

Fill PDF online

Rate (4.5 / 5) 11 votes
INSTRUCTIONS FOR PREPAID SERVICE PLANS
NEW OR RENEWAL APPLICATIONS
The attached documents comprise the application necessary to obtain a Certificate of
Registration as a prepaid legal or dental service plan in the State of Kansas. The completed
application should be submitted to the Kansas Insurance Department for processing. Although
the application is largely self-explanatory, a few specific instructions are listed below:
1. Copies of the enabling statutes are included. These statutes require that prospective plans
submit lists of individuals who will solicit memberships on their behalf. Such lists must
be updated and revised at six (6) month intervals. Prepaid service plans should make
several copies of the enclosed form and submit a revised list on January 1 and July 1 each
year.
2. A security deposit in the amount of $50,000 is required before issuance of a Certificate of
Registration to any new prepaid service plan. No membership fees may be collected prior
to issuance of the required Certificate of Registration.
3. When the amount of annual membership fees collected reaches $300,000 to $750,000, the
Commissioner of Insurance retains the authority to increase the deposit required to
$75,000. The Commissioner of Insurance may also increase the deposit to $100,000 when
the annual membership fees exceed $750,000.
4. Prepaid service plans submit copies of Certified Financial Audits prepared by a Certified
Public Accountant, provider agreements, membership agreements, sales brochures, and
other marketing material with this application. This allows the Kansas Insurance
Department to determine how the plan is structured and what membership benefits are
offered.
5. For questions or comments concerning the Prepaid Dental Service Plan application or the
application process, please contact Ms. Linda Griffin, Sr. Admin. Specialist at (785)
296-7850 or by email at Linda.Griffin@ks.gov.
For questions or comments concerning the Prepaid Legal Service Plan application or the
application process, please contact Ms. Heather Droge, Director, Property & Casualty
Division at (785) 296-7839 or by email at
Heather.Droge@ks.gov.
Please mail the application to the Kansas Insurance Department at 1300 SW Arrowhead
Road, Topeka, KS 66604.
INSTRUCTIONS FOR PREPAID SERVICE PLANS
NEW OR RENEWAL APPLICATIONS
The attached documents comprise the application necessary to obtain a Certificate of
Registration as a prepaid legal or dental service plan in the State of Kansas. The completed
application should be submitted to the Kansas Insurance Department for processing. Although
the application is largely self-explanatory, a few specific instructions are listed below:
1. Copies of the enabling statutes are included. These statutes require that prospective plans
submit lists of individuals who will solicit memberships on their behalf. Such lists must
be updated and revised at six (6) month intervals. Prepaid service plans should make
several copies of the enclosed form and submit a revised list on January 1 and July 1 each
year.
2. A security deposit in the amount of $50,000 is required before issuance of a Certificate of
Registration to any new prepaid service plan. No membership fees may be collected prior
to issuance of the required Certificate of Registration.
3. When the amount of annual membership fees collected reaches $300,000 to $750,000, the
Commissioner of Insurance retains the authority to increase the deposit required to
$75,000. The Commissioner of Insurance may also increase the deposit to $100,000 when
the annual membership fees exceed $750,000.
4. Prepaid service plans submit copies of Certified Financial Audits prepared by a Certified
Public Accountant, provider agreements, membership agreements, sales brochures, and
other marketing material with this application. This allows the Kansas Insurance
Department to determine how the plan is structured and what membership benefits are
offered.
5. For questions or comments concerning the Prepaid Dental Service Plan application or the
application process, please contact Ms. Linda Griffin, Sr. Admin. Specialist at (785)
296-7850 or by email at Linda.Griffin@ks.gov.
For questions or comments concerning the Prepaid Legal Service Plan application or the
application process, please contact Ms. Heather Droge, Director, Property & Casualty
Division at (785) 296-7839 or by email at
Heather.Droge@ks.gov.
Please mail the application to the Kansas Insurance Department at 1300 SW Arrowhead
Road, Topeka, KS 66604.
STATE OF KANSAS
Prepaid Legal of Dental Service Plans
Application for New or Renewal Certificate of Registration
Name of Prepaid Service Plan:
Street Address:
Telephone Number:
President of Prepaid Service Plan:
Fee:
$100 New
(
)
$50 Renewal (
)
Type of Prepaid Service Plan:
Legal (
)
Dental (
)
TO THE COMMISSIONER OF INSURANCE
Topeka, Kansas
On behalf of _________________________________________, of _______________________
(Name of prepaid service plan)
(City, State)
prepaid service plan created under the laws of the State of _________________________,
(State of Domicile)
I, ________________________________, hereby apply for a Certificate of Registration
(President)
pursuant to Kansas Statutes Annotated (K.S.A.) 40-4201, et seq. authorizing and empowering the
above-named prepaid service plan to operate in the State of Kansas until such Certificate is
suspended, revoked, or terminated by the Kansas Commissioner of Insurance.
Moreover, I pledge and certify that the above-named plan will abide by the following
regulations:
1. The applicant plan shall not act as a prepaid plan without a written agreement between
the plan and the provider and a written agreement between the plan and the member.
2. Such written agreements shall be retained as part of the official records of the plan for the
duration of the agreements, and for five (5) years thereafter.
3. Such written agreements shall contain provisions that include the requirements of. K.S.A.
40-4203 through K.S.A. 40-4207.
4. Applicant plan has not had any previous applications for registration as a prepaid plan
denied within the past five (5) years.
5. Applicant plan has not had any professional, vocational, or business license denied,
suspended, revoked, or restricted by any public authority in this or any other state, nor
has any such license been subjected to a monetary fine by any public authority, not has
such license been withdrawn or surrendered to avoid disciplinary action.
6. Applicant plan has not had any judgment rendered against it in any court of any
jurisdiction of the United States for its activities relating to the transaction of business as
a prepaid service plan.
7. Applicant plan has not been declared insolvent or discharged from bankruptcy within the
last five (5) years.
8. None of applicant plan's officers have been convicted in a criminal proceeding (excluding
minor traffic violations) within the past ten (10) years.
9. Whenever a member utilizes the services of the prepaid service plan under the terms of a
written contract required by K.S.A. 40-4202, the payment to the provider of any amount
on behalf of the member by the prepaid service plan shall be deemed payment to the
provider when received.
10. Applicant plan is the following type of entity (check only one):
(
) Individual
(
) Partnership
(
) Corporation
Sales Force
Attach Exhibit A (form enclosed) disclosing the information requested about those individuals
who solicit memberships in the plan. (Applies to New Applications only).
Financial Information
Plan’s financial condition as of calendar year ending December 31, __________
Capital/Surplus $_______________
Annual Membership Fees:
Total amount collected from members
nationwide for this calendar year
$_______________
Total amount collected from
members in Kansas only
$_______________
Deposit
For new application –
per K.S.A. 40-211 (a) (1)
$50,000 (
)
For renewal based on scale found
on instruction sheet – per K.S.A.
40-4211 (a)(3) and (4)
$75,000 (
)
$100,000 (
)
Other-per K.S.A. 40-4211 (a) (2) $_______________ (
)
An annual certified audit, prepared by a certified public accountant, and copies of membership and
provider agreements, must be submitted along with this application.
Certification
It is hereby certified that the prepaid service plan making this application is organized
under the laws of the State of ___________________________, and has complied with the
requirements of.K.S.A.40-4201, et seq. relating to such plan.
Finally, the undersigned swears under oath (s)he is the President of such plan, that (s)he
is authorized to execute and file this application, that (s)he has read and fully understands the
requirements of K.S.A. 40-4201, et seq. relating to such plan, and that the information contained
in this application is true and accurate to the best of his/her knowledge.
_________________________________________
Signature of Applicant (Or President if plan is a corporation)
Subscribed and sworn to before me this on this date: __________________________________.
_____________________________________
Notary Public
My Appointment Expires: ____________________________.
Page of 6