Free K-WC 129 - Certificate of Excess Insurance (Rev. 02-07) - Kansas

Division of Workers Compensation

DATE:______________________________________________

TO: DIVISION OF WORKERS COMPENSATION DEPARTMENT OF LABOR 800 SW JACKSON STE 600 TOPEKA KS 66612-1227 e-mail address ­ [email protected]

CERTIFICATE OF EXCESS INSURANCE

This certifies that a Workers Compensation Excess Insurance Policy has been issued and delivered to the employer named below, and that by issuance and delivery of said policy and the filing of this certificate of insurance, it is admitted that said excess policy was effective on the date stated below and that the coverage provided therein is applicable to benefits under the Workers Compensation Act of the state of Kansas and that said policy shall remain in full force and effect until 20 days after receipt by the Division of Workers Compensation of notice of its cancellation or expiration and/or non-renewal. Name of Employer Insured: Address: Name of Insurer: Address: Policy Number: Expiration Date: Effective Date:

FORM OF COVERAGE
*Specific Excess Policy Limit: Specific Retention: $ Policy Term: *Aggregate Excess

STATUTORY
(Per occurrence) (Per occurrence)

Policy Limit: $ Loss Fund Percentage: Minimum Loss Fund: $ Estimated Loss Fund: $ Policy Term:

If more than one insurer is providing coverage, you must provide separate certificates for each insurer. *No changes shall be made to the Self-insured Specific Retention Amount or other limits of the policy upon renewal until approval is granted by the Division of Workers Compensation.

Insurer Authorized Representative Signature
K-WC 129 (Rev. 2-07)

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