Free K-WC 105 (Rev. 7-04) - Kansas

State of Kansas Department of Labor Division of Workers Compensation

EMPLOYER'S APPLICATION OATH TO BECOME A SELF-INSURER

Your applicant ________________________________________________________________________________________
(Name of Corporation or City or County Government or Other Entity)

of _______________________________________________________, by ______________________________________, its
(Address) (President of Corporation or Official of City or County Government) (Name)

_______________________________________________________ hereby applies to the Division of Workers Compensation for permission to become a self-insurer as provided by the Laws of Kansas relating to Workers Compensation, and in support of same alleges and represents to the Division as true that it/he/she is financially able to carry its/his/her own risk on all of its/his/her employees, and hereto attaches a copy of its/his/her most recent five years of audited financial statements the most recent being dated ______________________________________________. Wherefore, your applicant prays that the Division of Workers Compensation designate it/him/her as a self-insurer, as defined in the above-named law.

(Official Title of Signer)

STATE OF _________________________________________, COUNTY OF __________________________________, ss: ______________________________________________________________________ being first duly sworn on oath, states: That he/she is ____________________________________________ of the ____________________________________________
(President or Official of City or County Government or other entity) (Location) (Name of Business or City or County Government or other entity)

whose home office is at ______________________________________________________________________ making this application to become a self-insurer under the Kansas Workers Compensation Law; that he/she has read the above application and documents attached and that the facts contained therein are true; that all allegations made in such application and documents attached are for the purpose of inducing the Division of Workers Compensation to grant such application; and that the duties and responsibilities therein alleged and required to be performed by this application will be fully carried out at the time and in the manner required and alleged to be performed.

(Person Making Oath)

Subscribed and sworn to before me this (S E A L) __________________ day of __________________, 20_____.

(Notary Public)

K-WC 105 (Rev. 7-04)

My commission expires_______________________________