Application for Split Coverage - Kentucky - Kentucky 2026

1. Click ‘Get Form’ to open the Application for Split Coverage in our editor.
2. Begin by entering your employer's name and address in the designated fields. Ensure that you also provide the Federal Employer Identification Number (FEIN) accurately.
3. In the section requesting details about the type of business and location, clearly specify the principal work force engaged in the business activities. This information is crucial for proper coverage assessment.
4. Next, indicate the insurance carrier that will cover your primary workforce. If there is a separate workforce at another location, repeat this process by providing their details and corresponding insurance information.
5. Complete any additional required fields, including dates and signatures. Make sure to have a representative of the employer sign and date the application.
6. Finally, review all entered information for accuracy before submitting your application through our platform.

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