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/66 KB)

WKC-15783-E (Electronic Version - pdf/214 KB)

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

Contact Information

For questions about this form, or if you need this form in an alternate format, please see the Content Contact (listed to the left)

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