Employer Notice of Divided-Workforce

Document Number:  WKC-15783-E

Description:  This form is filed by an employer that is establishing 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.

A client that intends to have a divided workforce shall notify the department of the intent on a from prescribed 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-15783) which you can print and complete by hand.

Content Contact: Kathy Froehlich

Document Attachments:

WKC-15783-E (Electronic Version - Word/75 KB)

WKC-15783 (Print Version - pdf/79 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

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