KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 135-A (Rev. 3-14) CANCELLATION OF FORM K-WC 135 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 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 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: Employer name:_______________________________________________________________________ Address:_____________________________________________________________________________ ____________________________________________________________________________________ Email:_______________________________________________________________________________ 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, or assignment to a community corrections program or suspension of sentence, or as a condition of probation or in lieu of a fine. Signature of 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