Free K-WC 135 (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 Persons Performing Public or Community Service as a Result of a Contract of Diversion, Assignment to a Community Corrections Program or Suspension of Sentence or as a Condition of Probation or in Lieu of a Fine
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 persons performing the following public or community service as a result of a contract of diversion, assignment to a community corrections program or suspension of sentence or as a condition of probation or in lieu of a fine. Classes of persons to be covered:_________________________________________________________ ____________________________________________________________________________________ Classes of persons NOT to be covered (if any):______________________________________________ ____________________________________________________________________________________ The employer agrees to cover such workers during such period of time they are performing the service under such conditions 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.

Signature of Authorized Representative

Title of Signing Individual

Date Signed K-WC 135 (Rev. 10-04)