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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the name of the individual to be covered under the Act in the designated field.
- Provide the Social Security number (SSN) in the corresponding section, ensuring accuracy for identification purposes.
- Fill in the email address and physical address of the individual, making sure all information is clear and legible.
- Enter the name of your business (DBA) if applicable, confirming that you are a sole owner, partner, or self-employed.
- Sign the form where indicated to validate your election under the Kansas Workers Compensation Act.
- Ensure that an authorized representative from your insurance carrier completes their section, including signature and coverage date.
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