Cancellation Of Election Of Employer To Provide Coverage For Persons Performing Public Service
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Cancellation Of Election Of Employer To Provide Coverage For Persons Performing Public Service Form. This is a Kansas form and can be use in Workers Compensation.
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Tags: Cancellation Of Election Of Employer To Provide Coverage For Persons Performing Public Service, K-WC-135a, Kansas Workers Compensation,
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 of Employer to Provide Workers
Compensation Coverage for Persons Performing Public or
Community Service as a Result of a Contract of Diversion,
Assignment to a Community Corrections Program or Suspension
of Sentence or as a Condition of Probation or in Lieu of a Fine.
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:
Employer Name:
____________________________________________________________________
Employer Address: ____________________________________________________________________
____________________________________________________________________
hereby cancels its previous election to provide workers compensation coverage for workers performing
public or community service as a result of a contract of diversion, assignment to a community corrections
program or suspension of sentence or as a condition of probation or in lieu of a fine within the provisions of
the Kansas Workers Compenstion Act.
Signature of Authorized Representative
Title of Signing Individual
Date Signed
K-WC 135a (Rev. 5-10)
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