Free K-WC 51 (Rev. 10-04).indd - Kansas

DIVISION OF WORKERS COMPENSATION KS DEPARTMENT OF LABOR
800 SW JACKSON ST STE 600 TOPEKA KS 66612-1227 Phone: 785-296-3441 ­ Fax: 785-296-0839 Web Site: www.dol.ks.gov

Election of Employer to Cover Employees Under Kansas Workers Compensation Act Where Employer has Less than $20,000 Payroll or is Agricultural Pursuit.
NOTICE: To be processed, ALL entries on this form must be completed. All entries, except signatures, must be neatly printed in black ink. NOTE: This Election is effective upon receipt by the Kansas Division of Workers Compensation.

To the Kansas Division of Workers Compensation, you are hereby notified that: Employer Name: ______________________________________________________________________ Corporate Name if Applicable: ___________________________________________________________ Address of Employment: _______________________________________________________________ ____________________________________________________________________________________ Telephone Number: (______)______________ Type of Business:________________________________ hereby elects to come within the provisions of the Kansas Workers Compensation Act pursuant to K.S.A. 44-505(b).

Valid Signature of Employer or Authorized Representative

Title of Signing Individual

Date Signed

K-WC 51 (Rev. 10-04)