Application For Approval Of Split Coverage Wrap Up {375}

Form 375 - APPLICATION FOR APPROVAL OF SPLIT COVERAGE WRAP UP (SPECIAL) PROJECTS. This form is used by Kentucky employers to request approval for split workers’ compensation insurance coverage under KRS 342.375. Employers may apply for separate coverage policies for distinct plants, job sites, or wrap-up (special) projects where workforces perform different duties and are not commingled. The application requires a cover letter explaining the need for split coverage, subcontractor lists for wrap-up projects, and a completed application form. Once approved, the employer’s carrier must submit proof of coverage for both the main entity and subcontractors, with monthly subcontractor reports filed until project completion. The form must be notarized and submitted to the Department of Workers’ Claims, Compliance Branch, in Frankfort. www.FormsWorkflow.com