Employee Leasing Company Notification of a client covered under a master policy for small clients under s. 102.315(5)(b), Wis. Stats. Department of Workforce Development Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 266-6827 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov This form must be filed with the Wisconsin Worker’s Compensation Division within 30 days of the effective date of a contract between an employee leasing company and a client under a master policy for small clients. COMPLETE ALL ITEMS OR THIS FORM WILL BE RETURNED TO YOU. If questions, call 608-266-3046. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. Employee Leasing Company Information 1. Legal Name of Employee Leasing Company 2. Employee Leasing Company Street Address City State Zip Code State Zip Code 3. Employee Leasing Company Federal Employer Identification Number 4. Effective Date of Employee Leasing Agreement 5. Name of Employee Leasing Company’s Worker’s Compensation Insurance Carrier For Leased Employees 6. Employee Leasing Company’s Worker’s Compensation Insurance Policy Number Client Information 1. Client Name 2. Client Street Address City 3. Client Federal Employer Identification Number 4. Client’s Other Commonly Owned or Controlled Entities, if any 5. Does the Client Have Operations in Any State Other Than Wisconsin? Yes, if yes, list the State(s) No 6. Nature of the Client’s Business 7. Number of Employees Leased Under the Employee Leasing Agreement 8. Client’s Estimated Unmodified Annual Premium Assignable to the Client’s Business for its Leased and Non-leased Workforce, including all commonly owned or controlled entities or organizations, without regard to split workforce or State location. Estimated Unmodified Annual Premium Assignable to the Client’s Leased Workforce Estimated Unmodified Annual Premium Assignable to the Client’s Non-leased Workforce .00 .00 $ $ 9. Classification Codes Applied to the Clients Leased Workforce and the Estimated Payroll Assigned to Each Code Code: Payroll $ Code: Payroll $ Code: Payroll $ Code: Payroll $ Code: Payroll $ Code: Payroll $ 10. Client Contact Name and Telephone Number Employee Leasing Company Representative Name (Please Print) Signature of Employee Leasing Company Representative Title Telephone Number Date Signed WKC-15784 (R. 04/2009) American LegalNet, Inc. www.FormsWorkFlow.com Section 102.315(1)(h), Wis. Stats. “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. Section 102.315(1)(j), Wis. Stats. “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. Section 102.315(5), Wis. Stats. MASTER POLICY; SMALL CLIENTS. (a) Regardless of whether a master policy has been approved under sub. (4), an employee leasing company may insure its liability under sub. (2) with respect to a group of small clients of the employee leasing company by obtaining a master policy in the voluntary market insuring that liability. The fact that an employee leasing company has a client that is covered under a mandatory risk−sharing plan under s. 619.01 does not preclude the employee leasing company from obtaining a master policy under this paragraph so long as that client is not covered under the master policy. An insurer may issue a master policy under this paragraph insuring in the voluntary market the liability under sub. (2) of an employee leasing company with respect to a group of small clients of the employee leasing company regardless of whether any of those small clients has a divided workforce. 1 (b) Within 30 days after the effective date of an employee leasing agreement with a small client that is covered under a master policy under par. (a), the employee leasing company shall report to the department all of the following information: 1. The name and address of the small client and of each entity or organization that is under common control or ownership with the small client. 2. The number of employees initially covered under the master policy. 3. The estimated unmodified annual premium assignable to the small client’s business, including the business of all entities or organizations that are under common control or ownership with the small client, without regard to whether the small client has a divided workforce, which information the small client shall report to the employee leasing company. 4. The effective date of the employee leasing agreement. (c) 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. Coverage of a small client under a master policy becomes binding when the insurer or employee leasing company files proof of that coverage under this paragraph or provides notice of coverage to the small client, whichever occurs first. Nothing in this paragraph requires an employee leasing company or an employee of an employee leasing company to be licensed as an insurance intermediary under ch. 628. (d) If at any time the unmodified annual premium assignable to the business of a small client that is covered under a master policy under par. (a), including the business of all entities or organizations that are under common control or ownership with the small client, without regard to whether the small client has a divided workforce, exceeds the threshold below which employers are not experience rated under the standards and criteria under ss. 626.11 and 626.12, the employee leasing company shall notify the insurer and obtain coverage for the small client under sub. (3) or (4). 1 An employee leasing company may obtain a master policy under this paragraph to cover its clients not eligible for experience rating, and simultaneously have a client or clients eligible for experience rating covered by the Wisconsin insurance pool, provided the client or clients covered by the Wisconsin insurance pool are not covered under the master policy. American LegalNet, Inc. www.FormsWorkFlow.com