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Termination Notice of Divided-Workforce

Document Number:  WKC-15782-E

Description:  This form is filed by an employer that is terminating its divided-workforce plan.

A "Divided Workforce Plan" means a plan under which two worker's compensation insurance policies are issued to cover the employees of a client that has a divided workforce, one policy covering the leased employees of the client and one policy covering the employees of the client who are not leased employees.

If a client intends to terminate a divided workforce plan, the client shall notify the department of that intent on a form prescribed by the department.  Termination of a divided workforce plan by a client is not effective until 10 days after notice of the termination is received by the department.

Comments:  Form is protected from modification and enabled for form fill (includes tabbed fields for form completion).  If you do not have Microsoft Word, the blank form can be printed and completed by hand.

Content Contact:  Don Martin

Document Attachment:  WKC-15782-E (Word/66 KB)

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