Company Licensing

Company Licensing

Risk Purchasing Group

Risk Retention Group

Mailing/Contact:

Heather Droge
Kansas Insurance Department
1300 SW Arrowhead Road
Topeka, KS 66604 – 4073
Phone: (785) 296-7839
Fax: (785) 291-3673
Email: kid.commissioner@ks.gov

Uniform Certificate of Authority Application

Kansas State Specific Forms

Please do not complete any of the forms listed below at the time of application. If your “Uniform Certificate of Authority Application” for a Kansas Certificate of Authority is approved, you will be contacted and requested to complete some of these forms depending upon the lines of business your company has applied to underwrite in Kansas.
For additional information contact Patrick Mulvihill by phone at 785-296-5350, or email at Patrick.Mulvihill@ks.gov.
All documents are in PDF format unless otherwise indicated.

LINE OF BUSINESS FORMS TO BE COMPLETED
Fire Form3, Form18, Form19
Windstorm & Hail Form18
Extended Coverage Form18
Add’l Perils on Growing Crops Form18
Hail on Growing Crops Form18
Optional Perils Form18
Sprinkler Leakage Form18
Business Interruption Form18
Earthquake Form18
Water Damage Form18
Aircraft Hull Form18
Ocean Marine Form18
Inland Marine Form18
Rain None
Auto Physical Damage Form23, Form3, Form22*, Form21*, Form7
Flood Form18
Homeowners Policies Form3
Farmowners Policies Form3
Automobile Liability Form23, Form3, Form22*, Form20*, Form21*, Form7, Form6
General Liability Form23, Form5, Form6
Workers Compensation Form23, Form5, Form6
Fidelity, Surety & Forgery Bonds Form23
Glass Form18
Burglary, Theft & Robbery Form23, Form3
Boiler & Machinery Form23, Form3
Credit Form23
Title None
Malpractice Liability Form23, Form5, Form6
Livestock Mortality Form23, Form3
Aircraft Liability Form23
Cargo Liability Form23, Form18

* you must complete two (2) copies of this form