Election Of Employer To Cover Employees Where Employer Has Less Than $20,000 Payroll
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Election Of Employer To Cover Employees Where Employer Has Less Than $20,000 Payroll Form. This is a Kansas form and can be use in Workers Compensation.
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Tags: Election Of Employer To Cover Employees Where Employer Has Less Than $20, 000 Payroll, K-WC 51, 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 Employer to Cover Employees Under
Kansas Workers Compensation Act Where Employer
has Less than $20,000 Payroll or is Agricultural Pursuit.
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:
Employer Name: ______________________________________________________________________
Corporate Name if Applicable: ___________________________________________________________
Address of Employment: _______________________________________________________________
____________________________________________________________________________________
Telephone Number: (______)______________ Type of Business:________________________________
hereby elects to come within the provisions of the Kansas Workers Compensation Act pursuant to
K.S.A. 44-505(b).
Valid Signature of Employer or Authorized Representative
Title of Signing Individual
Date Signed
K-WC 51 (Rev. 5-10)
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