Erm 14 Form PDF Details

Understanding the ERM-14 Form is crucial for businesses navigating the complexities of workers' compensation insurance policies. This form plays a vital role in keeping your insurance provider informed about any significant changes that could affect your premium. Whether it's a change in ownership, the sale of a portion of the business, or even a merger, timely reporting through the ERM-14 Form is not just a requirement; it's a safeguard for ensuring your policy stays up-to-date with the current state of your business. The form solicits detailed information about the nature of any transactions, the entities involved, and the resultant changes in business structure or ownership. Designed to ensure clarity and transparency, it not only helps in updating policy details but also aids in the accurate calculation of premiums, thereby preventing any unwelcome surprises in insurance costs. What makes it especially user-friendly is the option for businesses to submit the required information in a narrative format, adding a layer of convenience to the process. However, the meticulous need for complete and correct information, coupled with the strict 90-day reporting window, underscores the importance of attention to detail and timeliness when dealing with the ERM-14 form.

QuestionAnswer
Form NameErm 14 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameserm 14 work comp form, erm 14 form fillable, erm14, ownership information form

Form Preview Example

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 A—Contact 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 entity’s 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 owners’ names and percentages of ownership below.

ERM-14 (Rev. 2/20)

© Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved.

Page 1 of 2

Section D—Business Entity Information

Copies of this page may be submitted for transactions with more than three entities.

 

 

Entity 1

Entity 2

Entity 3

 

 

Entity before the change or

Entity after the change or

Entity after a merger or

 

Entity Information

to determine combinability

to determine combinability

consolidation or to determine

 

 

with another entity

with another entity

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: Owner(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

 

 

 

 

 

 

 

 

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

 

ERM-14 (Rev. 2/20)

© Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved.

Page 2 of 2

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