DIVISION OF WORKERS COMPENSATION KS DEPARTMENT OF LABOR 800 SW JACKSON ST STE 600 TOPEKA KS 66612-1227 Phone: 785-296-3441 – Fax: 785-296-0839 Web Site: www.dol.ks.gov Election Not to Accept Coverage Under Kansas Workers Compensation Act by Employee Who Owns 10% or More of Corporate Stock of Corporate Employer. 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 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 Employee Electing Out of Act: ____________________________________________________ Social Security Number of Employee: _____________________________________________________ Corporate Employer's Name and Address: __________________________________________________ Telephone Number: (______)________________ Type of Business:_____________________________ The above named employee states that he/she owns 10% or more of the corporate stock of the above corporation and elects, pursuant to K.S.A. 44-543, not to accept coverage under the Kansas Workers Compensation Act. The above named employee recognizes that by signing this form he/she is not covered under the Kansas Workers Compensation Act. _____________________________________________ Valid Signature of Employee Electing Out of Act _____________________________________________ Date Signed by Employee 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. K-WC 50 (Rev. 10-04) American LegalNet, Inc. www.USCourtForms.com