KANSASDEPARTMENTOFLABOR www.dol.ks.gov CERTIFICATE OF EXCESS INSURANCE K-WC129(Rev.6-12) DATE:___________________________________ ThiscertifiesthataWorkersCompensationExcessInsurancePolicyhasbeenissuedanddeliveredtotheemployer namedbelow,andthatbyissuanceanddeliveryofsaidpolicyandthefilingofthiscertificateofinsurance,itisadmitted thatsaidexcesspolicywaseffectiveonthedatestatedbelowandthatthecoverageprovidedthereinisapplicableto benefitsundertheWorkersCompensationActoftheStateofKansasandthatsaidpolicyshallremaininfullforceand effectuntil20daysafterreceiptbytheDivisionofWorkersCompensationofnoticeofitscancellationorexpirationand/or non-renewal. Nameofemployerinsured: Address: Nameofinsurer: Address: Policynumber: Expirationdate: Effectivedate: FORM OF COVERAGE *Specific Excess Policylimit:STATUTORY (Per occurrence) Specificretention:$ (Per occurrence) Policyterm: *Aggregate Excess Policylimit:$ Lossfundpercentage: Minimumlossfund:$ Estimatedlossfund:$ Policyterm: Ifmorethanoneinsurerisprovidingcoverage,youmustprovideseparatecertificatesforeachinsurer. *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 representativesignature Address DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone(785)296-4000·wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com