Free Form -375.PDF - Kentucky

APPLICATION FOR APPROVAL OF SPLIT COVERAGE

Pursuant to KRS 342.375, ________________________________________________ employer ___________________________________ _________________________________ address FEIN does hereby request authorization from the Commissioner of the Department of Workers' Claims to secure the employer' liability under KRS Chapter 342 through s separate insurance policies for specific plants or work locations. The applicant proposes that the principal work force of the employer, which is engaged in _______________________ at _______________________________ shall be covered type of business location(s) by __________________________________. A separate work force engaged in ____ insurance carrier _________________located at ____________________________________________ type of business location(s) shall be covered by ______________________________________issued by _______ policy number ________________________. Employees in the separate work forces have distinct duties and are not commingled. This the ______day of ____________, 19____.

_____________________________________ Representative of Employer

Subscribed and sworn to before me, this the _______day of ______________, 19___. _____________________________________ Notary Public My commission expires ________________________; County____________________
FORM .375