Kentucky > Workers Comp
Application For Approval Of Split Coverage 375 - Kentucky
| Application For Approval Of Split Coverage Form. This is a Kentucky form and can be used in Workers Comp . |
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APPLICATION FOR APPROVAL OF SPLIT COVERAGE Pursuant to KRS 342.375, ________________________________________________ employer ___________________________________ _________________________________ address FEINdoes hereby request authorization from the Commissioner of the Departmen t of Workers 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 engaged in _______________________ at _______________________________ shall be cove red type of business location(s) by __________________________________. A separate work force engaged i n ____ insurance carrier _________________located at ____________________________________________ type of business location(s) shall be covered by ______________________________________issued by ____ ___ policy number ________________________. Employees in the separate work forces have d istinctduties and are not commingled. This the ______day of ____________, 20____. _____________________________________ Representative of EmployerSubscribed and sworn to before me, this the _______day of ______________ , 20___. _____________________________________ Notary Public My commission expires ________________________; County__________________ __ FORM .375
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