Fill and Sign the Application for Split Coverage Kentucky Kentucky Form

PROCEDURES FOR WRAP-UP (SPECIAL) PROJECTS AND SPLIT COVERAGE FORM 375 & FORM 375 WRAP-UP The entity applying for the approval of split coverage shall supply the following information: 1. A cover letter indicating why split coverage is necessary. A contact name with phone number, fax number, and e-mail address must be included. 2. A list, if for wrap-up (special) project, of the sub- contractors that will be on the work site. 3. A completed application for split coverage by the requesting entity. After approval of the split coverage by the Department of Workers’ Claims, the carrier for the requesting entity must file the following: 1. Proof of coverage through the Electronic Data Interchange for the requesting entity. 2. Proof of coverage for sub-contractors listed for the wrap-up (special) project. a. Will only be accepted if coverage is on file for the requesting entity. 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’s liability under KRS Chapter 342 through 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 ____________, 20____. _____________________________________ Representative of Employer Subscribed and sworn to before me, this the _______day of ______________, 20___. _____________________________________ Notary Public My commission expires ________________________; County____________________ FORM .375