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ELECTION OF INDIVIDUAL TO COME UNDER ACT

ELECTION OF INDIVIDUAL TO COME UNDER ACT 2025

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The document outlines the process for individuals, including sole owners, partners, and self-employed individuals, to elect coverage under the Kansas Workers Compensation Act. It includes instructions for completing the election form, requirements for signatures and Social Security numbers, and a section for insurance carriers to confirm coverage. Additionally, it provides a disclosure regarding the use of Social Security numbers in compliance with federal privacy regulations.

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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. Ensure that this is accurate as it will be used for identification purposes.
Next, provide the Social Security Number (SSN) of the individual. This is mandatory for processing and must be entered correctly.
Fill in the email address and physical address of the individual. Make sure all information is clear and legible.
Indicate the name of your business (Doing Business As - DBA) if applicable. This helps in associating coverage with your business entity.
Sign the form where indicated to validate your election under the Kansas Workers Compensation Act.
Ensure that a representative from your insurance carrier completes their section, including their signature and title, to finalize coverage.

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