Wisconsin Proof of Coverage Notice

Document Number: WKC-15785-E

Description: This form is filed by the insurance carrier.

"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 coverage of a small client under a master policy under par. (a), the insurer or, if authorized by the insurer, the employee leasing company shall file proof of that coverage with 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-15785) which you can print and complete by hand.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-15785-E (Electronic Version - Word/66 KB)

WKC-15785 (Print Version - pdf/74 KB)

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