Free K-WC 51a (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

Cancellation of 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. Division of Workers Compensation.

NOTE: This Cancellation of Election is effective upon receipt by the Kansas

To the Kansas Division of Workers Compensation, you are hereby notified that: Name of Employer Cancelling Election: ____________________________________________________ Corporate Name, if applicable:___________________________________________________________ Address of Employer Cancelling Election:___________________________________________________ ____________________________________________________________________________________ Telephone Number: (_______)__________________ Type of Business:______________________________ hereby cancels its election(s) pursuant to K.S.A. 44-505(b) to come within the provisions of the Kansas Workers Compensation Act.

_____________________________________________
Valid Signature of Employer or Authorized Representative

_____________________________________________
Title of Signing Individual

_____________________________________________
Date Signed

K-WC 51a (Rev. 10-04)