Kansas > Workers Compensation
Election Of Individual To Come Under Act K-WC 113 - Kansas
| Election Of Individual To Come Under Act 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 113 (Rev. 6-12) ELECTION OF INDIVIDUAL TO COME UNDER ACT Election of Individual, Partner, Member of a Limited Liability Company or Self-Employed Individual to Come Within the Provisions of the Kansas Workers Compensation Act 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 and the Social Security number provided. 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: Name of individual to be covered under Act:_______________________________________________________ SSN:___________________________ Email:_____________________________________________________ Address of individual:_________________________________________________________________________ ___________________________________________________________________________________________ Name of business (DBA):______________________________________________________________________ being a sole owner of a business, partner, member of a limited liability company or self-employed individual does hereby elect, pursuant to K.S.A. 44-542a, to cover himself/herself as an individual under the coverage of the Kansas Workers Compensation Act. _______________________________________________________________________ Signature of individual THIS FORM IS NOT VALID UNLESS INSURANCE CARRIER OR GROUP FUNDED POOL COMPLETES THE BELOW PORTION. (NOTE: Cannot be completed by an insurance agent; must be completed by representative of carrier issuing policy.) The ____________________________________________________________ hereby agrees to Name of insurance carrier or group funded pool provide coverage for the above electing individual as of _______________________________________. First date of coverage (mm/dd/yy) ________________________________________________________________ Signature of representative Title ________________________________________________________________ ________________________________________________________________ Address of insurance carrier or group funded pool ________________________________________________________________ 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. 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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