ERM-14 (Rev. 2/20) © Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 2
REQUEST FOR OWNERSHIP INFORMATION—ERM-14 FORM
The purpose of this confidential form is to obtain ownership information to assist in calculating premium for your workers
compensation insurance policy. Your policy requires that you report ownership changes, and other changes as detailed
below, to your insurance carrier in writing within 90 days of the change. If you have questions, contact your agent,
insurance company, or the appropriate rating organization. Incomplete information or a missing signature may result
in a delay in processing.
The ownership information required on this ERM-14 Form can also be submitted in narrative form on the letterhead of the
employer, signed by an owner, partner, member, or executive officer.
Section AContact Information
Name of person completing this form ____________________________ Your Employer __________________________
Phone # _____________________________ Email Address ________________________________________________
Relationship to business entity reporting ownership information _______________________________________________
Section B—Transaction Information
Type of Transaction (check all that apply)
Transaction
Effective Date
Name and/or legal entity change
The name and/or legal status of the entity has changed. DBA name changes do not need to be reported.
Sale, transfer, or conveyance of all or a portion of an
entity’s ownership interest
Complete or partial sale of the business entitys ownership interest.
Sale, transfer, or conveyance of an entity’s physical
assets to another entity that takes
over its operations
An entity’s assets have been sold or transferred. The acquiring entity has taken over the operations, and
the selling entity retained its legal business name.
Merger or consolidation
Two or more entities have merged or combined to form a single entity.
Formation of a new entity that acts as, or in effect is, a successor to another entity that:
(Select one) Has dissolved Is nonoperative May continue to operate in a limited capacity
Formation of a new entity
A new entity has formed that is not a successor to another entity. Report this change only to determine
combinability with another entity.
An irrevocable trust or receiver, established either voluntarily or by court mandate
A change has occurred to the business, either voluntarily or by court mandate, requiring the entity to be put
in a trust or receivership.
Determination of combinability of separate entities
Two or more entities may need to be combined or separated based on their ownership interest.
Section C—Description of Transaction(s)
Include a brief description of the transaction(s) selected above. Attach additional information on the employer’s letterhead, if needed.
If this is a partial sale, transfer, or conveyance of an existing business (e.g., sale of one or more plants or locations), explain what
portion or location of the entire operation was sold, transferred, or conveyed.
If any of the entities that underwent a change in ownership were related through common ownership to any other entity before the
transaction described above, list the entities and their current ownersnames and percentages of ownership below.
ERM-14 (Rev. 2/20) © Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 2 of 2
Section D—Business Entity Information
Copies of this page may be submitted for transactions with more than three entities.
Section E—Certification
This is to certify that the information contained on this form is complete and correct.
_________________________________________________ _________________________ ________________________________
Signature of Owner, Partner, Member, or Executive Officer Title Business Name
_________________________________________________ _________________________
Print name of above signature Date
Entity Information
Entity 1
Entity before the change or
to determine combinability
with another entity
Entity 2
Entity after the change or
to determine combinability
with another entity
Entity 3
Entity after a merger or
consolidation or to determine
combinability with another entity
1. Name of Business
Provide the legal name of the
business entity.
2. Primary Address
(Street, City, State, Zip)
3. Legal Status
(See examples in item 4 below)
4. Ownership
List names of individual owners,
partners, etc. and percentages of
ownership (if applicable).
Ownership should total 100%.
Sole Proprietorship: Owner
Corporation: O
wner(s) and
percentages of ownership
General Partnership:
Partners and percentages of
ownership
Limited Partnership:
General partners and
percentages of ownership
Limited Liability Company:
Members and percentages of
ownership
Revocable Trust:
Grantor(s)
Irrevocable Trust: Trustee(s)
Other: If no voting stock, list
members of board of directors or
comparable governing body
5. FEIN
6. Risk ID Number
7. Policy Number
8. Policy Effective Date
9. Contact Name
10. Contact Phone/Email
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