ACORD 173 KS (2005/11)

Section Name
Field Name
Field and/or Section Description
ACORD 173 KS (2005/11)
Kansas Cancellation of Election
Not to Accept Coverage
Use this form to notify the Kansas Division of Workers Compensation that an employee
who owns 10% or more of the stock in a corporation elects to cancel a previous election
not to accept workers compensation insurance coverage.
ACORD 173 KS (2005/11)
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