Free K-WC 138 - Workers Compensation Election Information (Rev. 02-09) - Kansas

KANSAS DEPARTMENT OF LABOR www.dol.ks.gov

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WORKERS COMPENSATION ELECTION INFORMATION
K-WC 138 (Rev. 2-09)

The Kansas Workers Compensation Act allows certain employers or individuals to choose their status under the Act. This process is known as filing a written statement of election. Below are the various election forms presently in use: A. Form K-WC 50 is filed by an employee of a corporation who owns 10 percent or more of the corporate stock to elect not to be covered under the Act. Form K-WC 50a cancels a K-WC 50 election. (See K.S.A. 44-543(b)) Form K-WC 51 is filed by an employer that is exempt from the law to choose to be covered. This includes employers with less than a $20,000 payroll and employers involved in agricultural pursuits. Form K-WC 51a cancels the election made by K-WC 51. (See K.S.A. 44-505(b)) Form K-WC 113 is filed by an individual, proprietor, members of LLC's or partner to elect to cover himself or herself under the Act. Form K-WC 114 cancels the election made by K-WC 113. Both of these forms must be signed by a group pool administrator or an official of the insurance carrier. A signature of an agent is not acceptable. (See K.S.A. 44-542a) Form K-WC 123 is filed by an employer to elect to provide coverage for all or part of his or her volunteer workers. Form K-WC 124 cancels the election made by K-WC 123. (See K.S.A. 44-508(b)) Form K-WC 135 is filed by an employer to elect to provide coverage for persons who are performing public or community service as a requirement to receive public assistance or as a result of a contract or diversion, assignment to a community corrections program, or suspension of sentence or as a condition of probation or in lieu of a fine. Form K-WC 135a cancels the election made by K-WC 135. (See K.S.A. 44-508(b)) Form K-WC 137 is filed by volunteer directors, officers, or trustees of a nonprofit organization to elect coverage under the Workers Compensation Act. Form K-WC 137a cancels the election made by K-WC 137. (See K.S.A. 44-543(a))

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In order to be valid and in effect, an election must be filed with the Division of Workers Compensation. Election forms may be obtained from the Division of Workers Compensation at no charge or can be requested by telephone; call (785) 296-3441. Election forms are also available on the Division's Web site under Printable & Interactive Forms (http://www.dol.ks.gov/wc/html/ wcfrmpdf_All.html) Questions concerning the proper filing or use of elections can be referred to the Ombudsman/ Claims Advisory Section at (800) 332-0353.

DIVISION OF WORKERS COMPENSATION 800 SW Jackson Street, Suite 600, Topeka, KS 66612-1227 Phone (785) 296-2996 · Fax (785) 296-0025 · Toll Free (800) 332-0353