ACORD 171 KS (2005/11)

Section Name
Field Name
Field and/or Section Description
ACORD 171 KS (2005/11)
Kansas Election of Individual,
Partner, Member of a Limited
Liability Company or Self-
Employed Individual
Use this form to notify the Kansas Division of Workers Compensation that an employee
who is a member of a partnership or limited liability company or sole proprietor of a
business elects to be included in workers compensation insurance coverage.
ACORD 171 KS (2005/11)
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