ACORD 180 KS (2005/11)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 180 KS (2005/11)
Kansas Election of Coverage for
Persons Performing Public Service
ACORD 180 KS, Kansas Election of Coverage for Persons
Performing Public Service, is used to notify the Kansas Division of Workers Compensation
that an employer elects to provide workers compensation coverage for persons
performing public or community service as a result of a contract of diversion, assignment
to a community corrections program or suspension of sentence or as a condition of
probation or in lieu of a fine.
IDENTIFICATION SECTION Employer Name:
Enter text: The employer name (business name if self-employed).
IDENTIFICATION SECTION Employer Address:1
Enter text: The first address line of the employer's physical address.
IDENTIFICATION SECTION Employer Address:2
Enter text: The city of the employer's physical address.
IDENTIFICATION SECTION
Enter code: The state code of the employer's physical address.
IDENTIFICATION SECTION
Enter code: The postal code of the employer's physical address.
IDENTIFICATION SECTION covered:1
Classes of persons to be
Enter text: The description of employee classes that are covered on the policy.
IDENTIFICATION SECTION covered:2
Classes of persons to be
Enter text: The description of employee classes that are covered on the policy.
IDENTIFICATION SECTION covered (if any):1
Classes of persons Not to be
Enter text: The description of employee classes that are not covered on the policy.
IDENTIFICATION SECTION covered (if any):2
Classes of persons Not to be
Enter text: The description of employee classes that are not covered on the policy.
IDENTIFICATION SECTION Authorized Representative
Valid Signature of Employer or
Sign here: Accommodates the signature of the authorized representative of the employer.
IDENTIFICATION SECTION Title of Signing Individual
Enter text: The title of the authorized representative of the employer.
IDENTIFICATION SECTION Date Signed (MM/DD/YYYY)
Enter date: The date the form was signed by the employer.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 180 KS (2005/11) rev. 05-08-2009
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