KANSAS REFERENCE FILING AGREEMENT FORM

In accordance with the requirements of K.S.A. 40-216 and/or K.S.A. 40-955,

The (Name of Insurer) hereinafter referred to as Company, of (City and State of Domicile) hereby requests and authorizes the Kansas Commissioner of Insurance to accept a filing by reference of (Class of Insurance or Subdivision Thereof) as currently approved on behalf of (Licensed Rating Organization or Another Insurer)

Authorization is requested to permit this Company to file by reference the following:

Check the Box(es) Below / Material to be Referenced
1. Coverage parts, forms, endorsements and/or riders
2. Rates/Rating Plans
3. Rules
4. Loss Costs

The Company certifies that it will utilize material identical to that approved for

(Licensed Rating Organization or Another Insurer) by the Kansas Commissioner of Insurance. In addition, the Company understands that any future changes approved for the licensed rating organization or other insurer listed above all automatically apply to the material referenced in this agreement. Further, the Company agrees and certifies that, unless otherwise noted as Insurance department exceptions on the reverse side, future changes as approved for the licensed rating organization or other insurer by the Kansas Commissioner of Insurance will be applied and utilized on the same effective date as approved for such licensed rating organization or other insurer. The Company understands that if such approved changes are not automatically applied and utilized on the same effective date, the Company may be in violation of Kansas statutes.

Unless waived by the Commissioner, we agree annually, from the effective date of approval of this agreement to submit current, updated supporting information to justify continued approval of this reference filing agreement.

This reference agreement shall remain effective until terminated by the Commissioner of terminated by the Company with the approval of the Commissioner.

(Company)

By ______

(Signature of Official)

(Title)

I.Insurance Company Modification (To be completed by reference filing company):

There are no modifications to the rates, rules and/or forms being referenced in this agreement except as follows (Please declare that (1) the modified rates, rules and/or forms currently on file; or (2) that duplicate copies of such material is submitted with this agreement:

The reference filing company is:

Check the Box(es)
Below / Affiliation
Not a member of or subscriber to the licensed rating organization for the material being referenced.
Not affiliates with the insurer for the material being referenced
Affiliated with the insurer for the material being referenced

II.Insurance Department Exceptions (To be completed by Insurance Department):