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:  This form is an electronic Microsoft Word template that can filled out on your computer (if you have Microsoft Word). If you do not have Microsoft Word we are providing a PDF (WKC-15782) which you can print and complete by hand.

Content Contact: Kathy Froehlich

Document Attachments:

WKC-15782-E (Electronic Version - Word/66 KB)

WKC-15782 (Print Version - pdf/61 KB)

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