Form K-Wc 113 - Election Of Individual To Come Under Act

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KANSAS DEPARTMENT OF LABOR
ELECTION OF INDIVIDUAL TO COME UNDER ACT
K-WC 113 (Rev. 1-17)
MAIL: Division of Workers Compensation
401 SW Topeka Blvd., Suite 2
Topeka, KS 66603-3105
FAX: (785) 296-0025
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.
To the Kansas Division of Workers Compensation, you are hereby notified that:
Name of individual to be covered under Act:_______________________________________________________
SSN:___________________________ Email:_____________________________________________________
Address of business:_________________________________________________________________________
___________________________________________________________________________________________
Name of business (DBA):_________________________________________FEIN: ________________________
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

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