Wisconsin Proof Of Coverage Notice {WKC-15785}

WKC-15785 - WISCONSIN PROOF OF COVERAGE NOTICE UNDER A MASTER POLICY FOR SMALL CLIENTS UNDER S. 102.315(5)(C), WIS. STATS. This form is used to provide formal documentation to the Wisconsin Department of Workforce Development (DWD) that a small client of an employee leasing company is covered under a master worker’s compensation insurance policy. This form must be submitted within 30 days of the inception of coverage and must include a copy of the insurance policy naming the client as a covered insured. It collects information about the insured employee leasing company, the insurance carrier, and the client, including names, addresses, federal employer identification numbers, policy numbers, and effective dates of coverage. The purpose of the form is to comply with Chapter 102 of the Wisconsin Statutes and to ensure proper administration of worker’s compensation coverage for small clients, which are defined as clients with an unmodified annual premium below the threshold for experience rating. Filing this form allows the DWD to verify coverage under the master policy and ensures that the employee leasing company meets its reporting obligations regarding the number of employees covered, estimated premiums, and effective dates of employee leasing agreements. Completion of the form is required for timely administration of worker’s compensation benefits and to establish the binding nature of coverage for small clients under a master policy. www.FormsWorkflow.com