Kansas.gov

Forms and Publications

Accident Reports and Benefits

K-WC 107 - Benefit Cards (Rev. 06-14)
K-WC 140 - Death Benefit Information (Rev. 07-13)
K-WC 1070 A - Tabla De Beneficios Máximos (Rev. 6-14)
K-WC 1101 A - Accident Report (Rev. 10-13)
If this form is used, the employer must send the accident report to its insurance carrier, third party administrator or pool association for electronic submission to the Division of Workers Compensation.

Annual Reports

Annual Report 2013 (548 KB)
Annual Report 2012 (603 KB)
Annual Report 2011 (1.7 MB)
Annual Report 2010 (2.00 MB)
Annual Report 2009 (1.49 MB)
Annual Report 2008 (1.44 MB)
Annual Report 2007 (2.14 MB)
Annual Report 2006 (2.37 MB)
Annual Report 2005
Annual Report 2004
Annual Report 2003
Annual Report 2002   Errata Sheet
Annual Report 2001

Elections

K-WC 50 - Election of Employee Not to Accept Coverage (Rev. 03-14)
K-WC 50a - Cancellation of Form 50 (Rev. 03-14)
K-WC 51 - Employer to Cover Employees Under Act: gross annual payroll is $20,000
     or less, or agricultural pursuits (Rev. 03-14)
K-WC 51a - Cancellation of Form 51 (Rev. 03-14)
K-WC 113 - Individual, Partner, or Self-Employed to Come Under Act (Rev. 03-14)
K-WC 114 - Cancellation of Form 113 (Rev. 03-14)
K-WC 123 - Employer to Provide Coverage for Volunteer Workers (Rev. 03-14)
K-WC 124 - Cancellation of Form 123 (Rev. 03-14)
K-WC 135 - Employer to Provide Coverage for Persons Performing Public or Community
     Service (Rev. 03-14)
K-WC 135-A - Cancellation of Form 135 (Rev. 03-14)
K-WC 137 - Election of a Non compensated Volunteer Officer, Director, or Trustee of a
     Nonprofit Corporation to be Covered Rev. 03-14)
K-WC 137a - Cancellation of Form 137 (Rev. 03-14)
K-WC 138 - Workers Compensation Election Information (Rev. 05-14)

Employers and Employees

K-WC 25 - Workers Compensation Information for Kansas Employers and Employees (Rev.8-14)
K-WC 250 - Información Para Empleadores y Empleados (Rev. 08-14)
K-WC 27-A - Important Information for Injured Employees (Rev. 02-14)
K-WC 270-A - Información Importante Para Trabajadores Lastimados en el Trabajo (Rev. 02-14)
K-WC 40-A - "Posting" Notice (Rev. 04-13)
K-WC 126 - Independent Contractor or Employee? (Rev. 06-12)
K-WC 530 - Important Information for Employers Regarding Forms K-WC 27-A and 270-A (Rev. 10-13)

Fraud and Abuse

K-WC 44 - Report of Fraud or Abuse (Confidential) (Rev. 3-14)

Hearings and Settlements

K-WC D - Final Release (Rev. 03-14)
K-WC E 1 - Application for Hearing (Rev. 03-14)
K-WC E 2 - Surviving Spouse or Dependent / Heirs Application for Hearing (Rev. 03-14)
K-WC E 3 - Application for Preliminary Hearing (Rev. 03-14)
K-WC E 4 - Application for Post Award Medical (Rev. 03-14)
K-WC E 5 - Application for Review and Modification (Rev. 03-14)
K-WC E 6 - Application for Dismissal (Rev. 03-14)
K-WC 12 - Worksheet for Settlements: Injury Case (Rev. 03-14)
K-WC 13 - Worksheet for Settlements: Death Case (Rev. 05-14)
K-WC 28 - Information for Self-Represented Litigants (Rev. 06-12) has important information for injured workers
who are representing themselves in a hearing.
K-WC 112 - Annual Statement (Rev. 03-14)
K-WC 139 - Pre-Trial Stipulations (Rev. 12-12)
K-WC 160 - Statement Regarding Attorney Fees (Rev. 10-12)
K-WC 280 - Información Para Litigantes Representados A Si Mismos (Rev. 06-12) contiene información importante
para trabajadores lesionados que están representándose a si mismos en una audiencia.
K-WC 317 - Order for Production of Records (Rev. 10-12)
K-WC 321 - Joint Petition and Stipulation for Claim Settled (Rev. 6-13) Word     WordPerfect
K-WC 322 - Award on Joint Petition and Stipulation for Claim Settled (Rev. 6-13) Word     WordPerfect
K-WC 323 - Joint Petition and Stipulation for Reimbursement from WC Fund (Rev. 6-13) Word     WordPerfect
K-WC 324 - Order on Joint Petition and Stipulation for Reimbursement from WC Fund (Rev. 6-13) Word     WordPerfect
K-WC 325 - Award on Joint Petition and Stipulation for Structured Settlement or Annuity Contract (Rev. 6-13) Word     WordPerfect
K-WC 326 - Requirements for Joint Petition and Stipulations (Rev. 1-13)

Newsletter: Work Comp Connection

Subscribe by emailing Shirley.Hastings@dol.ks.gov
2014 Issues
2013 Issues
2012 Issues

Publications for Sale

K-WC 300 - Order Form for Workers Compensation Publications (Rev. 2-14)

Rehabilitation

K-WC-R 87-7 - Medical Management Closure Report (Rev. 09-13)
K-WC-R 93-2 - Vendor Referral Report (Rev. 09-13)
K-WC-R 93-2 IAMC - IAM CREST Vendor Referral Report (Rev. 09-13)
K-WC-R 93-3 - Rehabilitation Vendor Progress Report (Rev. 09-13)
K-WC-R 93-3A - Vocational Assessment (Rev. 09-13)
K-WC-R 93-3B - Rehabilitation Plan (Rev. 09-13)
K-WC-R 93-3C - Plan Amendment (Rev. 10-13)
K-WC-R 93-5 - Vocational Rehabilitation Closure Report (Rev. 02-14)
K-WC-R 93-6 - Rehabilitation Reporting Guidelines (Rev. 09-13)
K-WC-R 93-10 - Vocational Rehabilitation Vendor Application (Rev. 02-14)
K-WC-R 93-11 - Qualified Rehabilitation Professional Application (Rev. 02-14)
K-WC-R 93-12 - How to Become a Qualified Rehabilitation Professional (Rev. 03-14)
K-WC-R 93-13 - Important Reminders for Vendors and Qualified Rehabilitation Professionals (QRP) (Rev. 09-13)
K-WC-R 93-20 - Law & Regulations for Vocational Rehabilitation (Rev. 02-14)
K-WC-R 99-8 - Vendor's Request for Additional Expenditures (Rev. 02-14)

Requests for Records

K-WC 95 Records Download Requestor's Guide (Rev. 10-12)
K-WC 96 - Registration for Access to Electronic Records (Rev. 04-13)
K-WC 97 - Employers/Carrier's Request for Workers Compensation Records (Rev. 03-14)
K-WC 98 - Worker's Request for Workers Compensation Records (Rev. 03-14)
K-WC 308 - Affidavit Attesting to the Use of Public Records (Rev. 02-13)
K-WC 970 - Request for Workers Compensation Records / Solicitud de Datos de los
     Expedientes de Compensación de Trabajadores (Rev. 03-14)
K-WC 980 - Solicitud del Trabajador para Registros de Compensación de Trabajadores (Rev. 03-14)

Self-Insurance

K-WC 20 - Bank Fact Sheet (Rev. 06-12)
K-WC 105 - Employer's Application Oath to Become a Self-Insurer (Rev. 06-12)
K-WC 120 - Application for Self-Insurance (Rev. 06-12)
If you prefer to download an "interactive" Excel version of this form, select: K-WC 120 (Rev. 06-12) - Interactive
K-WC 121 - Assessment Information (Rev. 06-12)
K-WC 129 - Certificate of Excess Insurance (Rev. 06-12)
K-WC 130 - Irrevocable Letter of Credit (Rev. 02-14)
K-WC 130a - Trust Operational Agreement (Rev. 06-12)
K-WC 131 - Self-Insurance Aggregate Surety Bond (Rev. 08-13)
K-WC 131a - Amendatory Rider to Surety Bond (Rev. 06-12)
K-WC 132 - Indemnity and Guaranty Agreement (Rev. 06-12)
K-WC 133 - Statement of Insured (Rev. 06-12)
K-WC 144 - Self-Insurance Information (Rev. 06-12)
K-WC 309 - Why Audited Financial Statements are Required (Rev. 06-12)
K-WC 1441 - Information for Self-Insured Employers on the Kansas Workers Compensation Act and Regulations (Rev. 06-12)

Statutes and Regulations

Blue New icon Senate Substitute for HB 2023 This is the bill containing the addition (see italics, paragraph (c) on page 2) to the workers compensation statutes, signed by Governor Sam Brownback in 2014 and effective with its publication in the statute book. A summary of the changes can be accessed here.

The 2013 update to the Kansas Workers Compensation law book is now online.

Available in any of four options:

  • Download the complete updated book of Kansas workers compensation laws and regulations from the April 25, 2013 (Complete) link below.
  • Download a set of just the sections of the book in which changes occurred, along with an updated index from the April 25, 2013 (Changes Only) link below.
  • Order the complete updated book of Kansas workers compensation laws and regulations, and receive a three-hole binder to hold all the pages and divider sheets to organize your book into sections.
  • Order a three-hole punched packet of just the sections of the book in which changes occurred, along with an updated index.
April 25, 2013 Edition (Complete): Workers Compensation Laws and Regulations
This is the complete set of laws and regulations concerning workers compensation in Kansas, incorporating changes made in the 2013 legislative session, and 2013 regulatory changes.

The complete hard copy book is published in an 8.5” by 11.0” format with a three-ring binder which has pre-loaded full-color cover and spine inserts for easy locating on a desk or bookshelf. Each page of the inside contents is dated so that when there is a need to update the book, the pages of the affected sections will be revised, given a new effective date, and made available online for download and printing. The affected sections of the complete book can then be replaced by the updated pages.

April 25, 2013 Edition (Changes Only)
This is a set of update pages for the 2012 hard copy edition, to be printed out and three-hole punched for insertion into the 2012 edition binder in place of the pages currently there. These update pages, dated 4/25/13, contain the changes made in the 2013 legislative session, and the 2013 amendment to Kansas Administrative Regulation 51-9-17.

Senate Bill 187 This is the bill containing all changes (additions and deletions) to the workers compensation statutes, signed by Governor Sam Brownback in 2013. This is the enrolled bill version, complete with strikethroughs and italics. The statutes in the bill apply only to injuries sustained at work on or after April 25, 2013. The statutes became effective April 25, 2013. A summary of the changes can be accessed here.

Subpoenas

The following four forms are not available for download online but may be obtained by calling or writing to the Director’s secretary. See the Office Locations Directory for main office contact information.

K-WC 41 – Subpoena
K-WC 41-A – Subpoena Duces Tecum (in person)
K-WC 41-B – Deposition Subpoena/Deposition Subpoena Duces Tecum
K-WC 41-C – Subpoena Duces Tecum (evidence)