Applications and Forms

Our commitment to protecting and supporting our insureds while ensuring the long-term stability of the Kansas healthcare landscape makes us the top choice for medical liability coverage for Kansas physicians, healthcare providers, hospitals, and facilities.

physician filling out form in her office

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Supplemental Forms and Applications

Claim Information Worksheet

When applying for medical liability coverage, healthcare providers and facilities should use this worksheet to communicate to KAMMCO about any claims they may have received against them.

Collaborative Practice Agreement / Responsible Physician Form

This form is for non-physician healthcare providers who need to attest to a collaborative practice agreement or who must have a physician provide a statement regarding the care they provide.

Dentist Anesthesia Addendum

Dentists who use any kind of anesthesia in their practice must complete this form when applying for KAMMCO medical liability coverage.

Election of Payment Form

Complete and submit this form to select one of three options KAMMCO offers providers to pay their annual premiums.

Financing Form for Annual Premiums (CoreFirst Bank & Trust)

Complete and submit this form to apply for financing for your annual premium from CoreFirst Bank & Trust. You must return the completed form to CoreFirst.

Health Care Stabilization Fund, Notice of Basic Coverage Form

The Health Care Stabilization Fund (Fund) requires this form to be completed by all healthcare providers defined in Kansas statute K.S.A. 40-3401(f) who wish to practice in Kansas. The Fund provides excess medical professional liability coverage for these "defined" healthcare providers.

Kansas Medical Society (KMS) Physician Application

All KAMMCO-insured physicians must also be members of KMS. Follow this link to learn more about KMS membership and to complete a membership application.

KAMMCO Telemedicine Supplemental Questionnaire

This form must be completed by healthcare professionals applying for KAMMCO medical liability coverage.

KAMMCO Policy Cancellation Form

Complete and submit this form to cancel your KAMMCO medical liability policy.

W-9 Form

This form should be returned to KAMMCO when applying for or canceling coverage.

Additional Document Categories

New Business Applications

Higher Limits Coverage Applications

Policy Renewal Forms

Need Assistance?

Email underwriting@kammco.com or call 1-800-232-2259.

Additional Resources

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