Free FORM -375 WRAPUP.PDF - Kentucky

APPLICATION FOR APPROVAL OF SPLIT COVERAGE WRAP UP 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 other than ___________________________________ type of business wrap up policy location shall be covered by ___________________________________ issued by __________ wc policy number Insurance ___________________________. A separate work force engaged in _____________ Carrier type of ___________________________ located at _________________________________ business location of wrap up project shall be covered by ______________________________________________ issued by Policy number _____________________________. Employees in the separate work forces have Insurance Carrier 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 WRAP UP