Free Form -375.PDF - Kentucky

File Size: 4.9 kB
Pages: 1
File Format: PDF
State: Kentucky
Category: Workers Compensation
Author: jbullock
Word Count: 135 Words, 1,357 Characters
Page Size: Letter (8 1/2" x 11")

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Pursuant to KRS 342.375, ________________________________________________ employer ___________________________________ _________________________________ address FEIN does hereby request authorization from the Commissioner of the Department of Workers' Claims to secure the employer' liability under KRS Chapter 342 through s separate insurance policies for specific plants or work locations. The applicant proposes that the principal work force of the employer, which is engaged in _______________________ at _______________________________ shall be covered type of business location(s) by __________________________________. A separate work force engaged in ____ insurance carrier _________________located at ____________________________________________ type of business location(s) shall be covered by ______________________________________issued by _______ policy number ________________________. Employees in the separate work forces have distinct duties and are not commingled. This the ______day of ____________, 19____.

_____________________________________ Representative of Employer

Subscribed and sworn to before me, this the _______day of ______________, 19___. _____________________________________ Notary Public My commission expires ________________________; County____________________
FORM .375