This is one of the official Workers' Compensation forms for the state of Kentucky.
Kentucky Application for Split Coverage Wrap Up
State:
Kentucky
Control #:
KY-375W-WC
Format:
PDF
Instant download
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Public form
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Make edits, fill in missing information, and update formatting in US Legal Forms—just like you would in MS Word.
Download a copy, print it, send it by email, or mail it via USPS—whatever works best for your next step.
Sign and collect signatures with our SignNow integration. Send to multiple recipients, set reminders, and more. Go Premium to unlock E-Sign.
If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.
We protect your documents and personal data by following strict security and privacy standards.
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FAQ
The Kentucky Coal Employers Self-Insurance Guaranty Fund provides a safety net for coal operators who self-insure their workers' compensation obligations. This fund helps cover benefits for injured workers when coal operators cannot fulfill claims. If you operate in the coal industry, you may need to consider this fund when filling out the Kentucky Application for Split Coverage Wrap Up.
