Kentucky > Workers Comp
Application For Approval Of Split Coverage (Wrap Up) 375 - Kentucky
| Application For Approval Of Split Coverage (Wrap Up) Form. This is a Kentucky form and can be used in Workers Comp . |
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APPLICATION FOR APPROVAL OF SPLIT COVERAGE WRAP UP Pursuant to KRS 342.375, _______________________________________________ employer____________________________________, _________________________________ address FEINdoes hereby request authorization from the Commissioner of the Departmen t ofWorkers Claims to secure the employers liability under KRS Chapter 342 throughseparate insurance policies for specific plants or work locations. The applicantproposes that the principal work force of the employer, which is engage d in________________________at other than __________________________________ _ type of business wrap up policy locationshall be covered by ___________________________________ issued by ______ ____ wc policy number Insuranc e___________________________. A separate work force engaged in ________ _____ Carrier type of___________________________ located at ________________________________ _ business location of wrap up projectshall be covered by ______________________________________________ issue d by Policy number_____________________________. Employees in the separate work forces ha ve Insurance Carrier distinct duties and are not commingled. This the _______day of __________________, 20___. _____________________________________ Representative Of EmployerSubscribed and sworn to before me, this the _____day of _______________, 20 ___. _____________________________________ Notary PublicMy Commission expires _______________________; County ____________Form .375 WRAP UP
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