Form K-Wc 50 - Election Of Employee Not To Accept Coverage
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1KANSAS DEPARTMENT OF LABOR
ELECTION OF EMPLOYEE NOT TO ACCEPT COVERAGE
K-WC 50 (Rev. 6-12)
Election Not to Accept Coverage Under
Kansas Workers Compensation Act by Employee Who Owns
10 Percent or More of Corporate Stock of Corporate Employer
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
employee must sign this form and include his/her Social Security number.
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 employee electing out of Act: ___________________________________________________________
Social Security number: _______________________________________________________________________
Corporate business name and address: __________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Email: _____________________________________________________________________________________
Phone: (______)___________________
Type of business:__________________________________________
hereby states that he/she owns 10 percent or more of the corporate stock of the above corporation
and elects, pursuant to K.S.A. 44-543, not to accept coverage under the Kansas Workers
Compensation Act. The above named employee recognizes that by signing this form he/she is not
covered under the Kansas Workers Compensation Act.
_____________________________________________
Signature
_____________________________________________
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 • wcelections@dol.ks.gov
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