Free K-WC 135a (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 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 Cancellation of 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 cancels its previous election to provide workers compensation coverage for workers 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 within the provisions of the Kansas Workers Compenstion Act.

Signature of Authorized Representative

Title of Signing Individual

Date Signed

K-WC 135a (Rev. 10-04)