DIVISION OF WORKERS COMPENSATION KS DEPARTMENT OF LABOR 800 SW JACKSON ST STE 600 TOPEKA KS 66612-1227 Phone: 785-296- – Fax: 785-296-0025 Web Site: www.dol.ks.gov 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. NOTICE: To be processed, ALL entries on this form must be completed. All entries, except signatures, must be neatly printed in black ink. To the Kansas Division of Workers Compensation, you are hereby notified that: Name of Individual to be Covered under Act: _________________________________________________ Name of Business (DBA): ________________________________________________________________ Social Security Number of Electing Individual: ________________________________________________ Address of Electing Individual: ___________________________________________________________ ____________________________________________________________________________________ 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 Compenstion Act. _________________________________________________________ Valid Signature of Individual Electing to be Covered Under the Act THIS FORM IS NOT VALID UNLESS INSURANCE CARRIER OR GROUP FUNDED POOL COMPLETES THE BELOW PORTION. (NOTE: Cannot be completed by insurance agent. Must be completed by representative of carrier issuing policy.) The ____________________________________________________________ hereby agrees to provide Name of Insurance Carrier or Group Funded Pool coverage for the above electing individual as of ______________________________________________ First Date of Coverage (month/day/year) _________________________________________________________________ Signature of Representative of Insurance Carrier issuing policy or Group Funded Pool Representative _________________________________________________________________ Title of Representative Signing Above _________________________________________________________________ _________________________________________________________________ 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. K-WC 113 (Rev. 10) American LegalNet, Inc. www.FormsWorkFlow.com