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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 is a form from the Kansas Department of Labor for individuals, partners, members of limited liability companies, or self-employed individuals to elect coverage under the Kansas Workers Compensation Act. It requires completion of personal and business information, including Social Security number, and must be signed by both the individual and a representative from an insurance carrier. The form emphasizes that it is not valid without the insurance carrier's section being completed.

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