KANSAS DEPARTMENT OF LABOR
EMPLOYER'S APPLICATION OATH TO BECOME A SELF-INSURER
K-WC 105 (Rev. 6-12)
Your applicant _______________________________________________________________________________ of
(Name of Corporation or City or County Government or Other Entity)
______________________________________________________, by ____________________________________, its
(Name)
(Address)
_______________________________________________________ hereby applies to the Division of Workers
(President of Corporation or Official of City or County Government)
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)
(Name of Business, City or County Government or other entity)
whose home office is at ______________________________________________________________________ making
(Location)
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
________________ day of __________________, 20_____.
(S E A L)
(Notary Public)
My commission expires_______________________________
DIVISION OF WORKERS COMPENSATION
401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 • Phone (785) 296-4000 • wcselfinsurance@dol.ks.gov
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