Form K-Wc 137 - Election Of A Noncompensated Volunteer Officer, Director Or Trustee - 2014

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KANSAS DEPARTMENT OF LABOR
ELECTION OF A NONCOMPENSATED VOLUNTEER
OFFICER, DIRECTOR OR TRUSTEE
MAIL: Division of Workers Compensation
K-WC 137 (Rev. 3-14)
401 SW Topeka Blvd., Suite 2
Topeka, KS 66603-3105
FAX: (785) 296-0025
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
electing individual must sign this form and include his/her Social Security number.
This Election is effective upon receipt by the Kansas Division of Workers Compensation.
To the Kansas Division of Workers Compensation, you are hereby notified that:
Electing individual: ___________________________________________________________________________
Social Security number: _______________________________________________________________________
Phone: (_______)_____________________ Email: ________________________________________________
Nonprofit corporation: ________________________________________________________________________
Corporation address: _________________________________________________________________________
__________________________________________________________________________________________
hereby elects to come within the provisions of the Kansas Workers Compensation Act pursuant to
K.S.A. 44-543(c).
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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