KANSAS DEPARTMENT OF LABOR
CANCELLATION OF FORM K-WC 137
MAIL: Division of Workers Compensation
K-WC 137-A (Rev. 3-14)
401 SW Topeka Blvd., Suite 2
Topeka, KS 66603-3105
FAX: (785) 296-0025
Cancellation of Election of a Noncompensated Volunteer Officer,
Director or Trustee of a Nonprofit Corporation to be Covered
Under 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. The individual
cancelling his/her previous election must sign this form an include his/her Social Security
number.
This Cancellation of Election is effective upon receipt by the Kansas Division of Workers
Compensation.
To the Kansas Division of Workers Compensation, you are hereby notified that:
Name: ____________________________________________________________________________________
Social Security number: ____________________ Phone: ___________________________________________
Email:___________________________________________________________________________________
Nonprofit corporation: ________________________________________________________________________
Corporation address: _________________________________________________________________________
__________________________________________________________________________________________
hereby cancels his/her previous election to come within the provisions of the Kansas Workers
Compensation Act.
__________________________________________
Signature
__________________________________________
Title/Position
__________________________________________
Date
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
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