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


File Size: 540.1 kB
Pages: 1
Date: May 29, 2009
File Format: PDF
State: Kansas
Category: Workers Compensation
Word Count: 154 Words, 1,306 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dol.ks.gov/wc/html/kwc51(Rev-10-04)ReaderE.pdf

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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)