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Employee Leasing Company Notification

Document Number:  WKC-15784-E

Description:  This form is filed by an employee leasing company.

"Master policy" means a single worker's compensation insurance policy issued by an insurer authorized to do business in this state to an employee leasing company in the name of the employee leasing company that covers more than one client of the employee leasing company.

"Small client" means a client that has an unmodified annual premium assignable to its business, including the business of all entities or organizations that are under common control or ownership with the client, that is equal to or less than the threshold below which employers are not experience rated under the standards and criteria under ss. 626.11 and 626.12 without regard to whether the client has a divided workforce.

Within 30 days after the effective date of an employee leasing agreement with a small client that is covered under a master policy under par. (a), the employee leasing company shall report to the department all of the following information:

1. The name and address of the small client and of each entity or organization that is under common control or ownership with the small client.
2. The number of employees initially covered under the master policy.
3. The estimated unmodified annual premium assignable to the small client's business, including the business of all entities or organizations that are under common control or ownership with the small client, without regard to whether the small client has a divided workforce, which information the small client shall report to the employee leasing company.
4. The effective date of the employee leasing agreement.

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-15784-E (Word/87 KB)

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