KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 137-A (Rev. 3-14) CANCELLATION OF FORM K-WC 137 MAIL: Division of Workers Compensation 401 SW Topeka Blvd., Suite 2 Topeka, KS 66603-3105 FAX: (785) 296-0025 Cancellation of Election of a Noncompensated Volunteer Officer, Director or Trustee of a Nonprofit Corporation to be Covered Under 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. The individual cancelling his/her previous election must sign this form an 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: ____________________________________________________________________________________ Social Security number: ____________________ Phone: ___________________________________________ Email:___________________________________________________________________________________ Nonprofit corporation: ________________________________________________________________________ Corporation address: _________________________________________________________________________ __________________________________________________________________________________________ hereby cancels his/her previous election to come within the provisions of the Kansas Workers Compensation Act. __________________________________________ Signature __________________________________________ Title/Position __________________________________________ 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