Pursuant to Kansas Statutes Annotated 40-3106, the undersigned hereby applies for a certificate of Self-Insurance as a Nonresident Self-Insurer. 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. 40-3106.

• For each state where both the Applicant is authorized as a self-insurer and one of the Applicant's vehicles registered in the state may be driven in Kansas, Applicant has sent a copy of the self-insurer authorization by an agency of the state to KDOI.RF@ks.gov.
• Applicant certifies compliance with the coverage requirements of K.S.A. 40-3107.
• Applicant has sent evidence of financial ability to pay judgments against the applicant via financial reports to KDOI.RF@ks.gov.