Free K-WC 123 (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 Provide Workers Compensation Coverage for Volunteer Workers
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:______________________________________________________________________ Employer Address:____________________________________________________________________ hereby elects to cover volunteer workers who are engaged in the following volunteer work:____________ ____________________________________________________________________________________ Those volunteer workers in the following work are not being brought under the Act:__________________ ____________________________________________________________________________________ The employer agrees to cover such volunteer workers until such election shall be cancelled on a form provided by the Division of Workers Compensation. The employer further agrees to provide coverage through the employer's workers compensation insurance policy or through an already existing approved self-insurance plan.

Valid Signature of Employer or Authorized Representative

Title of Signing Individual

Date Signed

K-WC 123 (Rev. 10-04)