Free K-WC 114 (Rev. 10-04).indd - Kansas

DIVISION OF WORKERS COMPENSATION KS DEPARTMENT OF LABOR
800 SW JACKSON ST STE 600 TOPEKA KS 66612-1227 Phone: 785-296-4000 ­ Fax: 785-296-0025 Web Site: www.dol.ks.gov

Cancellation of Election of Individual, Partner, Member of a Limited Liability Company, or Self-Employed Individual to Come Within the Provisions of the Kansas Workers Compensation Act.
NOTICE: To be processed, ALL entries on this form must be completed.
To the Kansas Division of Workers Compensation, you are hereby notified that: Individual Cancelling Election: _________________________________________________________________ Name of Business (DBA): ____________________________________________________________________ Social Security Number of Electing Individual: ____________________________________________________ Address of Individual Cancelling Election: _______________________________________________________ ________________________________________________________________________________________ hereby cancels his/her previous election to come within the provisions of the Kansas Workers Compensation Act. ___________________________________________________
Valid Signature of Individual Cancelling Previous Election

All entries, except signatures, must be neatly printed in black ink.

THIS FORM IS NOT VALID UNLESS INSURANCE CARRIER OR GROUP FUNDED POOL ADMINISTRATOR COMPLETES THE BELOW PORTION. (NOTE: Cannot be completed by an insurance agent. Must be completed by representative of carrier issuing policy.) The _______________________________________________________________ states that the above
(Name of Insurance Carrier or Group Funded Pool)

individual who is cancelling his/her election is no longer insured by this carrier or Group Funded Pool. The coverage ceased or will cease on _____________________________________.
(Date)

_________________________________________________________
Signature of Representative of Insurance Carrier or Group Funded Pool Issuing Policy

_________________________________________________________
Title of Representative Signing Above

_________________________________________________________ _________________________________________________________
Address of Insurance Carrier or Group Funded Pool

Federal Privacy Act Disclosure Section 7(a)(2)(B)
The mandatory requirement that social security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. The use of social security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the social security number. K-WC 114 (Rev. 10-04)