Fill and Sign the Application for Split Coverage Wrap Up 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 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’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 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 __________________, 20___. _____________________________________ Representative Of Employer Subscribed and sworn to before me, this the _____day of _______________, 20 ___. _____________________________________ Notary Public My Commission expires _______________________; County ____________ Form .375 WRAP UP