KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 114 (Rev. 3-14) CANCELLATION OF FORM K-WC 113 MAIL: Division of Workers Compensation 401 SW Topeka Blvd., Suite 2 Topeka, KS 66603-3105 FAX: (785) 296-0025 Cancellation of Election of Individual, Partner, Member of a Limited Liability Company or Self-Employed Individual to Come Within the Provisions of 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. This form must be signed and the individual's Social Security number provided. 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: Individual cancelling election:____________________________________________________________________ SSN:_________________________ Email:_______________________________________________________ Address of individual:__________________________________________________________________________ ___________________________________________________________________________________________ Name of business (DBA):_______________________________________________________________________ hereby cancels his/her previous election to come within the provisions of the Kansas Workers Compensation Act. Signature of individual _____________________________________________________________________ THIS FORM IS NOT VALID UNLESS INSURANCE CARRIER OR GROUP FUNDED POOL ADMINISTRATOR COMPLETES THE BELOW PORTION. (NOTE: Cannot be completed by an insurance agent; must be completed by representative of carrier issuing policy.) The ____________________________________________________________ states that the above individual who is cancelling his/her election is no longer insured by this carrier or group funded pool. The coverage ceased or will cease on ______________________. Date Signature of representative Title Name of insurance carrier or group funded pool ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Address of insurance carrier or group funded pool ______________________________________________________________ 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. 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