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 be 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: Lynn Weinberger

Document Attachments:

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

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

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