KANSAS DEPARTMENT OF LABOR www.dol.ks.gov CANCELLATION OF FORM K-WC 50 K-WC 50-A (Rev. 3-14) MAIL: Division of Workers Compensation 401 SW Topeka Blvd., Suite 2 Topeka, KS 66603-3105 FAX: (785) 296-0025 Cancellation of Election Not to Accept Coverage Under the 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 Cancellation of 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 employee cancelling election: ___________________________________________________________ Social Security number: _______________________________________________________________________ Corporate business name and address: __________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Email: _____________________________________________________________________________________ ( ) Phone: _____________________________ Type of business:________________________________________ hereby cancels his/her election made pursuant to K.S.A. 44-543 to elect not to accept coverage under the Kansas Workers Compensation Act. The above named employee recognizes that by signing this form he/she will now be covered under the Kansas Workers Compensation Act. _____________________________________________ Signature _____________________________________________ Date 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. Federal Privacy Act Disclosure Section 7(a)(2)(B) DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000 · Fax (785) 296-0025 American LegalNet, Inc. www.FormsWorkFlow.com