KANSAS DEPARTMENT OF LABOR www.dol.ks.gov EMPLOYER'S APPLICATION OATH TO BECOME A SELF-INSURER K-WC 105 (Rev. 6-12) Your applicant _______________________________________________________________________________of (Name of Corporation or City or County Government or Other Entity) ______________________________________________________, by ____________________________________, its (Address) (Name) _______________________________________________________ hereby applies to the Division of Workers (President of Corporation or Official of City or County Government) Compensation for permission to become a self-insurer as provided by the Laws of Kansas relating to Workers Compensation, and in support of same alleges and represents to the Division as true that it/he/she is financially able to carry its/his/her own risk on all of its/his/her employees, and hereto attaches a copy of its/his/her most recent five years of audited financial statements the most recent being dated ______________________________. Wherefore, your applicant prays that the Division of Workers Compensation designate it/him/her as a self-insurer, as defined in the above-named law. (Official Title of Signer) STATE OF ______________________________________, COUNTY OF _____________________________________, ss: _________________________________________________________________ being first duly sworn on oath, states: That he/she is _________________________________________ of the ________________________________ (President or Official of City or County Government or other entity) (Location) (Name of Business, City or County Government or other entity) whose home office is at ______________________________________________________________________ making this application to become a self-insurer under the Kansas Workers Compensation Law; that he/she has read the above application and documents attached and that the facts contained therein are true; that all allegations made in such application and documents attached are for the purpose of inducing the Division of Workers Compensation to grant such application; and that the duties and responsibilities therein alleged and required to be performed by this application will be fully carried out at the time and in the manner required and alleged to be performed. (Person Making Oath) Subscribed and sworn to before me this ________________ day of __________________, 20_____. (S E A L) (Notary Public) My commission expires_______________________________ DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000 · wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com