Pursuant to Kansas Statutes Annotated 66-1,128, the undersigned hereby applies for a certificate of Self-Insurance as a public Motor Carrier of property, household goods, or passengers, or a private Motor Carrier of property. Any person in whose name more than 25 motor vehicles are registered in Kansas may qualify as a self-insurer by obtaining a certificate of self-insurance from the commissioner of insurance. The undersigned applicant affirms they meet all the requirements for a certificate of self-insurance included in K.S.A. 66-1,128.

• Applicant has this date ore than twenty-five (25) vehicles registered and will continue to have registered more than twenty-five (25) vehicles.
• Applicant is possessed and will continue to be possessed of the ability to pay any liability imposed by law against applicant arising out of the ownership, operation, maintenance or use of any motor vehicle registered in its name.
• Applicant certifies compliance with the coverage requirements of K.S.A. 40-3107.