Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 172 KS (2005/11)
Kansas Cancellation of 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 sole proprietor of a business elects to cancel a
previous election to be included in workers compensation insurance coverage.
ACORD 172 KS (2005/11)
1 of 1