Kansas Health Care Stability Fund

Section A - Health Care Provider Identification and Residency Status
- 1. Kansas License Number*
- 2. Provider Type*
  - Individual
  - Business
- 2a. Profession
- 2b. Facility Type
3. Last Name OR Business Name*
Enter the Health care providers last name or the complete name of medical facility or business entity name.
- 4. Professionals First Name
- 5. Middle Name or Initial
- 6. Suffix
- 7. Telephone Number*
- 8. Email Address

9. Legal Residence
Legal residence address of health care professional or street address location of medical care facility or business: NOTE: For health care professionals, this must be the home address (legal domicile).
9a. Street Address*
- 9b. Residence City*
- 9c. State*
- 9d. ZIP
- 9e. ZIP Ext.
10. Business Mailing Address
- 10a. Name of group practice, medical clinic, or other business
- 10b. Street Address or PO Box
- 10c. City
- 10d. State
- 10e. ZIP
- 10f. ZIP Ext.

Section B - Commercial Insurance Information
NOTE: A certificate of insurance is required for all non-resident health care providers. The information on this compliance form will not be accepted nor will the health care provider be in compliance with KSA 50-3401 et seq until the certificate of insurance and the appropriate HCSF premium surcharge have been received and accepted.
- 11a. Insurance Company Name*
- 11b. If field 11a = 'Other' then please enter Company Name
- 12a. Street Address or PO Box*
- 12b. City*
- 12c. State*
- 12d. ZIP*
- 12e. ZIP Ext.
- 13a. Policy Number*
- 14a. Effective Date*
  MM slash DD slash YYYY
- 14b. Expiration Date*
  MM slash DD slash YYYY
- 15. Type of Professional Liability*
- 16. HCSF Coverage limits per claim/annual aggregate*
- 17. Annual Premium*
- 18. Any unique features of this insurance policy?

Section C - Health Care Stabilization Fund Coverage
19. HCSF rate classification group number*
- 20. For Kansas residents only - Active Missouri license (yes or no)*
- 21. HCSF coverage level: (5=$500k/$1.5 million)*
- 22. HCSF compliance year (1 - if greater than 1 years, please select 1)*
- 23. Pro-rata year percent - please enter only the number without the % sign.
24. Annual HCSF Premium Surcharge*
25. For non-residents only - ratio (percent) of practice allocated in Kansas
26. For both residents and non-residents - calculated HCSF Premium Surcharge (minimum=$200*

Section D - Certification
For insurers of Kansas resident health care providers:
- By selecting this box, I hereby certify that all the information provided via this document is correct and that the health care provider named in this document is aware of his or her coverage options pursuant to Kansas law and has deliberately selected the coverage level indicated on this form.
- Name of insurance company representative
- Rep Phone Number
- Rep Email
For health care providers who are not legal residents of Kansas, but have an active license to practice in Kansas:
- By selecting this box, I hereby certify that: (1) all information provided via this document is correct, (2) I have deliberately selected the HCSF coverage level, (3) the percentage indicated is a reliable estimate of the ratio of my Kansas practice compared to my entire practice, and (4) at this time I have no knowledge of any kind of professional liability claim or lawsuit attributable to my Kansas practice.
Attachment(s)
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Method of Payment*
- Online Payment
- Mail Check

Section A - Health Care Provider Identification and Residency Status