Form K-Wc 113 - Cancellation Of Form - 2014

Download a blank fillable Form K-Wc 113 - Cancellation Of Form - 2014 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form K-Wc 113 - Cancellation Of Form - 2014 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

KANSAS DEPARTMENT OF LABOR
MAIL: Division of Workers Compensation
CANCELLATION OF FORM K-WC 113
401 SW Topeka Blvd., Suite 2
Topeka, KS 66603-3105
K-WC 114 (Rev. 3-14)
FAX: (785) 296-0025
Cancellation of Election of Individual, Partner, Member of a Limited
Liability Company or Self-Employed Individual to Come Within
the Provisions of the Kansas Workers Compensation Act
To be processed, ALL entries on this form must be completed. If not completed using the
fillable form feature, entries must be neatly printed in black ink or typewritten. This form must
be signed and the individual's Social Security number provided.
This Cancellation of Election is effective upon receipt by the Kansas Division of Workers
Compensation.
To the Kansas Division of Workers Compensation, you are hereby notified that:
Individual cancelling election:____________________________________________________________________
SSN:_________________________ Email:_______________________________________________________
Address of individual:__________________________________________________________________________
___________________________________________________________________________________________
Name of business (DBA):_______________________________________________________________________
hereby cancels his/her previous election to come within the provisions of the Kansas Workers
Compensation Act.
_____________________________________________________________________
Signature of individual
THIS FORM IS NOT VALID UNLESS INSURANCE CARRIER OR GROUP FUNDED POOL
ADMINISTRATOR COMPLETES THE BELOW PORTION. (NOTE: Cannot be completed by an
insurance agent; must be completed by representative of carrier issuing policy.)
The ____________________________________________________________ states that the above
Name of insurance carrier or group funded pool
individual who is cancelling his/her election is no longer insured by this carrier or group funded pool.
The coverage ceased or will cease on ______________________.
Date
______________________________________________________________
Signature of representative
______________________________________________________________
Title
______________________________________________________________
Address of insurance carrier or group funded pool
______________________________________________________________
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.
DIVISION OF WORKERS COMPENSATION
401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 • Phone (785) 296-4000 • Fax (785) 296-0025

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form K-wc 113 - Election Of Individual To Come Under Act Form K-wc 113 - Election Of Individual To Come Under Act Legal
Form K-wc 137 - Election Of A Noncompensated Volunteer Officer, Director Or Trustee - 2014 Form K-wc 137 - Election Of A Noncompensated Volunteer Officer, Director Or Trustee - 2014 Legal
Form K-wc 50 - Election Of Employee Not To Accept Coverage Form K-wc 50 - Election Of Employee Not To Accept Coverage Legal
Form 1099-c - Cancellation Of Debt - 2014 Form 1099-c - Cancellation Of Debt - 2014 Financial
Form K-120 - Kansas Corporation Income Tax - 2014 Form K-120 - Kansas Corporation Income Tax - 2014 Financial
Form K-41 - Kansas Fiduciary Income Tax - 2014 Form K-41 - Kansas Fiduciary Income Tax - 2014 Financial
Form Esl - Extension Of Statute Of Limitations 2014 Form Esl - Extension Of Statute Of Limitations 2014 Financial
Form 65 - Idaho Partnership Return Of Income - 2014 Form 65 - Idaho Partnership Return Of Income - 2014 Financial
Form Mo-1065 - Partnership Return Of Income - 2014 Form Mo-1065 - Partnership Return Of Income - 2014 Financial
Form 65 - Idaho Partnership Return Of Income - 2014 Form 65 - Idaho Partnership Return Of Income - 2014 Financial

Related Categories

Parent category: Legal
Download
Go