WKC-15783-E, Employer Notice of Divided-Workforce Skip main navigation

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  3. WKC-15783-E, Employer Notice of Divided-Workforce

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 be filled out on your computer (if you have Microsoft Word). An electronic PDF (WKC-15783-E) is also provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-15783-E (Electronic Version - Word/67 KB)

WKC-15783-E (Electronic Version - pdf/156 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.

Contact Information