TEXAS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY MANUAL |
WC-RFI |
1st Reprint |
Effective May 1, 1994 |
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REQUEST FOR INFORMATION |
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The following ownership statements are for use in establishing premiums for your workers' compensation |
coverages under |
the Experience Rating Plan. It is extremely important that all questions be answered completely. If you have any questions, |
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contact your agent or your insurance company. Submit the completed form to your insurance company. |
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PURPOSE (Check One) |
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Name change only |
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Complete column A for former name and column B for new name. |
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Complete only questions 1, 2 and 3 on page 2. |
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_____ Combination of separate entities |
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Complete a separate column for each entity related through common ownership (attach additional forms if |
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necessary). |
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_____ Sale, transfer or conveyance of ownership interest |
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Complete column A for ownership before the change and column B for ownership after the change. |
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Merger or consolidation |
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Complete columns A and B for the former entities and column C for the surviving entity. |
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_____ Formation of a new entity |
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Complete column A. |
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_____ Sale, transfer or conveyance of an entity's physical assets to another entity which takes over its operations
Complete column A for the former entity and column B for the acquiring entity.
INFORMATION |
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B |
C |
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Name and street address of Entity |
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(P. O. Box Numbers are not |
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acceptable) |
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Legal Status of Entity (Corporation, |
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Partnership, Sole Proprietor, |
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Trustee, Receiver, Limited |
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Partnership, etc.) |
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Ownership |
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Corporations--List names of |
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owners of 100% voting stock and |
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number of shares owned.* (Submit |
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shareholder proposal if transaction |
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involved exchange of stock.) |
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Partnerships--List each general |
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partner and appropriate share in |
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the profits. (If limited partnership, |
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list name of general partner.) |
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Other--If no voting stock, list |
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members, board of directors or |
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comparable governing body. |
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* Total shares of voting stock issued |
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Date of Ownership Change, |
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Acquisition, or Combinability |
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Insuring Company, Policy Number |
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and Effective Date |
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WC-RFI
REQUEST FOR INFORMATION
1.Has this entity operated under another name in the last four years? _________
2.Is the entity currently related through common majority ownership to any entity not listed on the front of the form?
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3.Has this entity been previously related through common majority ownership to any other entities in the last four years?
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If you answered yes to 1, 2, or 3 above, please provide the following information:
Name of |
Principal |
Carrier and |
Effective |
Business |
Location |
Policy Number |
Date |
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4.Were the assets and/or ownership interest (all or a portion) of this entity acquired from a previously existing business?
If yes, you must provide complete ownership information of the prior owner in column A and ownership information on the new owner in column B on the reverse side of this form.
5.Did the entity involved also undergo a change in operations sufficient to result in a change to its governing classification? If yes, attach a detailed explanation supporting these changes.
6.If this is a partial sale, transfer, or conveyance of an existing business (i.e., sale of one or more plans or locations): a. Explain what portion or location of the entire operation was sold, transferred, or conveyed.
b. Was this entity insured under a separate policy from the remaining portion? |
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If not, specify the |
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entities with which it was combined: |
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c. What entities will the seller maintain majority ownership of after this change?
This is to certify that the information contained on this form is complete and correct.
Name of insured:
Name of person completing form:
Signature of Owner, Partner or |
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Executive Officer |
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Print name of above signature |
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Date |
WC-RFI