Election Of A Noncompensated Volunteer Officer Director Or Trustee Of A Nonprofit Corporation Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Election Of A Noncompensated Volunteer Officer Director Or Trustee Of A Nonprofit Corporation Form. This is a Kansas form and can be use in Workers Compensation.
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Tags: Election Of A Noncompensated Volunteer Officer Director Or Trustee Of A Nonprofit Corporation, K-WC 137, 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
Election of a Noncompensated Volunteer Officer, Director or
Trustee of a Nonprofit Corporation to Be Covered Under
Kansas Workers Compensation Act.
N
OTICE: 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:
Employee’s Name: _____________________________________________________________________
Employee’s Social Security Number: ______________________________________________________
Nonprofit Corporation Name: ______________________________________________________________
Address of Nonprofit Corporation: _________________________________________________________
____________________________________________________________________________________
Telephone Number: (_______)_____________________
hereby elects to come within the provisions of the Kansas Workers Compensation Act pursuant
to K.S.A. 44-543(c).
Signature of Employee
Title/Position
Date Signed
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 137 (Rev. 5-10)
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