KANSAS DEPARTMENT OF LABOR www.dol.ks.gov CANCELLATION OF FORM K-WC 51 K-WC 51-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 of Employer to Cover Employees Under Kansas Workers Compensation Act, Where Employer Has Less than $20,000 Payroll or is Agricultural Pursuit 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. 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 employer cancelling election: ___________________________________________________________ Corporate name, if applicable:___________________________________________________________________ Address:____________________________________________________________________________________ __________________________________________________________________________________________ Email: _____________________________________________________________________________________ ( ) Phone: ____________________________ Type of business:__________________________________________ hereby cancels its election(s) pursuant to K.S.A. 44-505(b) to come within the provisions of the Kansas Workers Compensation Act. _____________________________________________ Signature of employer or authorized representative _____________________________________________ Title _____________________________________________ Date 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