APPLICATION FOR REGISTRATION
TO ACCESS THE ELECTRONIC APPLICATION SUBMISSION INTERFACE (EASi)
KENTUCKY AUTOMOBILE INSURANCE PLAN
PRINT IN INK OR TYPE APPLICATION
FOR PLAN USE
PROCESSED BY AND DATE
MAIL APPLICATION AND COPY OF LICENSE TO:
KENTUCKY AUTOMOBILE INSURANCE PLAN
P.O. Box 6530
Providence, RI 02940-6530
RECEIVED
REGISTRATION ID CODE
P & C INSURANCE AGENT/BROKER LICENSE NUMBER EXPIRATION DATE TAX ID # OR SOCIAL SECURITY #
LAST NAME/OR AGENCY NAME (AS IT APPEARS ON PRODUCER’S LICENSE) FIRST NAME MI
DBA (AS IT APPEARS ON PRODUCER’S LICENSE)
STREET ADDRESS (REQUIRED) CITY STATE ZIP CODE
MAILING ADDRESS CITY STATE ZIP CODE
TELEPHONE NUMBER (INCLUDING AREA CODE) FAX NUMBER (INCLUDING AREA CODE)
IF AN INDIVIDUAL, NAME OF AGENCY/BROKERAGE ASSOCIATED WITH:* AGENCY LICENSE NUMBER AGENCY REGISTRATION ID CODE
*NOTE: IF AGENCY IS NOT REGISTERED, PLEASE COMPLETE AND ATTACH AN APPLICATION FOR AGENCY REGISTRATION.
REGISTRATION TO ACCESS THE ELECTRONIC APPLICATION SUBMISSION INTERFACE SHALL NOT BE CONSTRUED AS CONSTITUTING THE
PRODUCER NAMED ABOVE AS AN AGENT OF THE KENTUCKY AUTOMOBILE INSURANCE PLAN OR ANY COMPANY TO WHICH AN APPLICANT IS
ASSIGNED. IN ALL TRANSACTIONS BETWEEN THE PRODUCER AND THE PLAN, THE PRODUCER SHALL BE DEEMED TO BE THE AGENT OF THE
APPLICANT AND NOT THE AGENT OF THE PLAN OR ANY COMPANY TO WHICH AN APPLICANT IS ASSIGNED.
IF YOU HAVE ANY QUESTIONS ON THE KENTUCKY AUTOMOBILE INSURANCE PLAN REGISTRATION PROGRAM OR THE PROPER
COMPLETION OF THIS FORM, PLEASE CONTACT CUSTOMER SERVICE AT (800) 555-0513. FAILURE TO INCLUDE A LICENSE COPY WILL
RESULT IN THE RETURN OF YOUR APPLICATION. IF ADDITIONAL COPIES OF THIS APPLICATION FORM ARE NEEDED, THIS FORM MAY BE
PHOTOCOPIED.
APPLICANT’S DECLARATION
THE APPLICANT NAMED ABOVE, OR THEIR REPRESENTATIVE, DECLARES THAT IN THE EVENT OF REGISTRATION AS A PRODUCER WHO MAY
ACCESS EASi AND ELECTRONICALLY TRANSMIT KENTUCKY AUTOMOBILE INSURANCE PLAN APPLICATIONS, THE APPLICANT WILL COMPLY
WITH ALL PLAN RULES AND REGULATIONS. ADDITIONALLY, THEY CERTIFY THAT ALL INFORMATION ON THIS APPLICATION IS TRUE AND
CORRECT AND THE COPY OF THE LICENSE IS AS ISSUED BY THE STATE DEPARTMENT OF INSURANCE. ANY MISREPRESENTATION OF
MATERIAL INFORMATION OR ALTERATION OF THE LICENSE WILL RESULT IN THEIR REGISTRATION BEING DECLARED INVALID.
_______________________________________________________ ________________________________________ ______________________
SIGNATURE OF APPLICANT OR AUTHORIZED REPRESENTATIVE PRINTED NAME DATE
PRODUCER REMARKS PLAN REMARKS
PLEASE MAKE SURE TO INCLUDE A COPY OF YOUR LICENSE WITH THIS SUBMISSION.
THIS FORM MAY ALSO BE EMAILED TO KYAIP@AIPSO.COM
AIP 7556 . 04/18
