DIVISION OF WORKERS COMPENSATION KS DEPARTMENT OF LABOR 800 SW JACKSON ST STE 600 TOPEKA KS 66612-1227 Phone: 785-296-2996 – Fax: 785-296-0025 Web Site: www.dol.ks.gov Cancellation of Election Not to Accept Coverage Under the Kansas Workers Compensation Act by Employee Who Owns 10% or More of Corporate Stock of Corporate Employer. NOTICE: To be processed, ALL entries on this form must be completed. All entries, except signatures, must be neatly printed in black ink. NOTE: 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 of Employee:______________________________________________________ Corporate Employer: (name) ____________________________________________________________ (address) ____________________________________________________________ ____________________________________________________________ Telephone Number: (_______)_________________ 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. _____________________________________________ Valid Signature of Employee Cancelling Election _____________________________________________ Date Signed by Employee 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 50a (Rev. 5-10) American LegalNet, Inc. www.FormsWorkFlow.com