Election Of Employer To Provide Workers Compensation Coverage For Volunteer Workers
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Election Of Employer To Provide Workers Compensation Coverage For Volunteer Workers Form. This is a Kansas form and can be use in Workers Compensation.
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Tags: Election Of Employer To Provide Workers Compensation Coverage For Volunteer Workers, K-WC 123, Kansas Workers Compensation,
DIVISION OF WORKERS COMPENSATION
KS DEPARTMENT OF LABOR
800 SW JACKSON ST STE 600
TOPEKA KS 66612-1227
Phone: 785-296- – Fax: 785-296-0
Web Site: www.dol.ks.gov
Election of Employer to Provide
Workers Compensation Coverage for Volunteer Workers
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:______________________________________________________________________
Employer Address:____________________________________________________________________
hereby elects to cover volunteer workers who are engaged in the following volunteer work:____________
____________________________________________________________________________________
Those volunteer workers in the following work are not being brought under the Act:__________________
____________________________________________________________________________________
The employer agrees to cover such volunteer workers until such election shall be cancelled on a form provided by the Division of Workers Compensation. The employer further agrees to provide coverage through
the employer's workers compensation insurance policy or through an already existing approved self-insurance plan.
Valid Signature of Employer or Authorized Representative
Title of Signing Individual
Date Signed
K-WC 123 (Rev. 10)
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