Pursuant to Kansas Statutes Annotated 40-3104, 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. 40-3104.

• Applicant has the responsibility to immediately notify the Kansas Department of Insurance at any time the total number of registered vehicles is less than this requirement.
• 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. 3116.
• Applicant has sent evidence of financial ability to pay judgments against the applicant to kdoi.rf@ks.gov