Kansas > Workers Compensation
Election Of Employer To Cover Employees K-WC 51 - Kansas
| Election Of Employer To Cover Employees Form. This is a Kansas form and can be used in Workers Compensation . |
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KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 51 (Rev. 6-12) ELECTION OF EMPLOYER TO COVER EMPLOYEES Election of Employer to Cover Employees Under Kansas Workers Compensation Act, Where Employer has less than $20,000 Payroll or is Agricultural Pursuit To be processed, ALL entries on this form must be completed. If not completed using the fillable form feature, entries must be neatly printed in black ink or typewritten. This form must be signed. This Election is effective upon receipt by the Kansas Division of Workers Compensation. This form may be emailed to wcelections@dol.ks.gov. To the Kansas Division of Workers Compensation, you are hereby notified that: Employer name: _____________________________________________________________________________ Corporate name if applicable: __________________________________________________________________ Address: ___________________________________________________________________________________ __________________________________________________________________________________________ Email: ____________________________________________________________________________________ Phone: (______)_________________ Type of business: ____________________________________________ hereby elects to come within the provisions of the Kansas Workers Compensation Act pursuant to K.S.A. 44-505(b). Signature of employer or authorized representative Title Date DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000 · Fax (785) 296-0025 · wcelections@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com
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