Free or Trustee of a Nonprofit Corporation to be Covered (Rev. 10-04) Reader-Enabled - 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 a Noncompensated Volunteer Officer, Director or Trustee of a Nonprofit Corporation to Be Covered Under Kansas Workers Compensation Act.
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: Employee's Name: _____________________________________________________________________ Employee's Social Security Number: ______________________________________________________ Nonprofit Corporation Name: ______________________________________________________________ Address of Nonprofit Corporation: _________________________________________________________ ____________________________________________________________________________________ Telephone Number: (_______)_____________________ hereby elects to come within the provisions of the Kansas Workers Compensation Act pursuant to K.S.A. 44-543(c).

Signature of Employee

Title/Position

Date Signed

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 137 (Rev. 10-04)