Free Service Contract Agreement - Kentucky



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This is to verify that the service contract between ____________________________________ (Employer) and _____________________________________________meets the requirements set forth in (Service Company) administrative regulation 803 KAR 25:021 3(4) and therefore contains one of the two following provisions: (A) The service organization shall adjust to a final conclusion any and all claims that result from an occurrence during the period for which the contract is effective unless a substitute service organization has been procured; OR (B) The service organization shall adjust any and all claims for a period of sixty (60) days following an order from the Commissioner finding the self- insured employer in default unless a substitute service organization has been procured. _________________________________________________ Signature of authori

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This is to verify that the service contract between ____________________________________ (Employer) and _____________________________________________meets the requirements set forth in (Service Company) administrative regulation 803 KAR 25:021 3(4) and therefore contains one of the two following provisions: (A) The service organization shall adjust to a final conclusion any and all claims that result from an occurrence during the period for which the contract is effective unless a substitute service organization has been procured; OR

(B)

The service organization shall adjust any and all claims for a period of sixty (60) days following an order from the Commissioner finding the self- insured employer in default unless a substitute service organization has been procured.

_________________________________________________ Signature of authorized Service Company Representative Date ______________________

__________________________________________________ Signature of authorized Self- Insured Employer Representative Date ______________________

File Size: 3.4 kB
Pages: 1
File Format: PDF
State: Kentucky
Category: Workers Compensation
Author: kmckenzi
Word Count: 125 Words, 1,061 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.labor.ky.gov/NR/rdonlyres/7A87DC6E-9E19-4D64-B9D6-F1E02ED435EC/0/ServiceContractAgreement.pdf