14 Form Pdf Details

The ERM 14 form is an important document for businesses and organizations of all sizes. The form helps companies manage risk and stay compliant with regulations. This guide provides an overview of the ERM 14 form, including its purpose and key components. Additionally, we'll discuss how to complete the form and what to do if you have any questions. Having a firm understanding of the ERM 14 will help you protect your business and ensure compliance with state and federal requirements.

The table contains specifics of the erm 14 form. There, you'll obtain the information about the PDF you would like to fill in, like the estimated time for you to complete it along with other data.

QuestionAnswer
Form NameErm 14 Form
Form Length4 pages
Fillable?Yes
Fillable fields192
Avg. time to fill out39 min 28 sec
Other nameserm form, how to erm 14, erm14, form 14

Form Preview Example

 

APPENDIX

Experience Rating Plan Manual—2003 Edition

A1

 

 

ERM-14 FORM—CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION

EFFECTIVE 01 DEC 2003

All items must be answered completely or the form may be returned.

The following confidential ownership statements may be used only in establishing premiums for your insurance coverages. Your workers compensation 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. Once completed, this form must be submitted to the rating organization by you, your insurance carrier(s), or your agents. If this form does not provide the means to explain the transaction, enter as much information on the form as possible and supplement the form with a narrative on the employer’s letterhead, signed by an owner, partner, or executive officer.

Section A—Transaction and Entity Information

Check all

Type of Transaction

 

 

 

Effective Date

 

Reported Date

Columns A, B, and C referenced below are found in

Enter effective date of

 

Enter date reported in writing to your

that apply

Section B.

 

 

 

transaction

 

insurance provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and/or legal entity change—Complete column A for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

former entity and column B for newly named entity. Complete

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Entity portion for each entity to reflect such change.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sale, transfer or conveyance of all or a portion of an

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

entity’s ownership interest—Complete column A for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ownership before the change and column B for ownership

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

after the change.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sale, transfer or conveyance of an entity’s physical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

assets to another entity that takes over its operations—

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete column A for the former entity and column B for the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

acquiring entity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Merger or consolidation (attach copy of agreement)—

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete columns A and B for the former entities and column

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C for the surviving entity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Formation of a new entity that acts as, or in effect is, a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

successor to another entity that: (a) Has dissolved (b) Is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

non-operative (c) May continue to operate in a limited

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

capacity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

An irrevocable trust or receiver, established either

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

voluntarily or by court mandate—Complete column A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

before the change and column B after the change.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Determination of combinability of separate entities—

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete a separate column in Section B for each entity to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

be reviewed for common ownership (attach additional forms if

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

necessary).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTITY 1—Complete Column A on Page 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Name of Entity (including DBA or TA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risk ID

 

 

 

 

 

 

 

 

FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Entity (check all that apply) Carrier

 

 

 

Policy #

 

 

 

 

Eff. Date

 

¨ Sole Proprietorship

¨ Limited Partnership

¨ Temporary Labor Service ¨ School District

¨ Irrevocable Trust

¨ Partnership

 

 

¨ Limited Liability Corporation

¨ Publicly Traded

 

 

¨ For Profit

 

¨ Religious Organization

¨ Domestic Corporation

¨ Joint Venture

¨ State Agency

 

 

¨ Not for Profit

 

¨ Charitable Organization

¨ Foreign Corporation

¨ Association (including unincorporated)

¨ County Agency

 

 

¨ Non-Profit

 

¨ Franchise

¨ Sub-Chapter S-Corp

¨ Employee Leasing

¨ Municipality

 

 

¨ Revocable Trust

¨ ESOP

Primary Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

 

 

 

Telephone Number

 

Fax Number

 

E-mail Address

 

 

 

 

 

Contact Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Web Site

 

 

 

 

 

 

Mailing Address (if different than Primary Address)

Additional Location(s)

ERM-14 (Rev. 12/03)

Page 1 of 4

© 2002 National Council on Compensation Insurance, Inc.

Oct 2003 (1)

APPENDIX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A2

 

 

 

 

 

 

 

 

Experience Rating Plan Manual—2003 Edition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTITY 2—Complete Column B on Page 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Name of Entity (including DBA or TA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risk ID

 

 

 

 

 

 

 

 

FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Entity (check all that apply)

Carrier

 

 

Policy #

 

 

 

 

 

 

 

Eff. Date

 

 

¨ Sole Proprietorship

¨ Limited Partnership

¨ Temporary Labor Service

¨ School District

¨ Irrevocable Trust

¨ Partnership

¨ Limited Liability Corporation

¨ Publicly Traded

¨ For Profit

¨ Religious Organization

¨ Domestic Corporation

¨ Joint Venture

¨ State Agency

¨ Not for Profit

¨ Charitable Organization

¨ Foreign Corporation

¨ Association (including unincorporated)

¨ County Agency

¨ Non-Profit

¨ Franchise

¨ Sub-Chapter S-Corp

¨ Employee Leasing

¨ Municipality

¨ Revocable Trust

¨ ESOP

Primary Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Fax Number

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Web Site

 

 

 

 

 

 

 

 

 

Mailing Address (if different than Primary Address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Location(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTITY 3—Complete Column C on Page 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Name of Entity (including DBA or TA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risk ID

 

 

 

 

 

 

 

 

FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Entity (check all that apply)

Carrier

 

 

Policy #

 

 

 

 

 

 

 

Eff. Date

 

 

¨ Sole Proprietorship

¨ Limited Partnership

¨ Temporary Labor Service

¨ School District

¨ Irrevocable Trust

¨ Partnership

¨ Limited Liability Corporation

¨ Publicly Traded

¨ For Profit

¨ Religious Organization

¨ Domestic Corporation

¨ Joint Venture

¨ State Agency

¨ Not for Profit

¨ Charitable Organization

¨ Foreign Corporation

¨ Association (including unincorporated)

¨ County Agency

¨ Non-Profit

¨ Franchise

¨ Sub-Chapter S-Corp

¨ Employee Leasing

¨ Municipality

¨ Revocable Trust

¨ ESOP

Primary Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

 

 

 

 

 

 

Telephone Number

 

Fax Number

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Web Site

 

 

 

 

 

 

 

 

 

Mailing Address (if different than Primary Address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Location(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section B—Ownership

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Have any of these entities operated under another name in the last four years? ¨ Yes ¨ No

 

 

 

 

 

 

 

 

2.

Are any of the entities currently related through common majority ownership to any entity not listed on the front of the form? ¨ Yes ¨ No

3.

Have any of these entities been previously related through common majority ownership to any other entities in the last four years?

 

¨ Yes ¨ No

 

 

4.

If you answered Yes to questions 1, 2, or 3 above, provide additional information, indicating which question(s) your answer references:

 

¨ 1 ¨ 2

¨ 3

 

 

 

Name of

Principal

Carrier and

Effective

 

Business

Location

Policy Number

Date

_____________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

5. Were the assets and/or ownership interest (all or a portion) of this entity acquired from a previously existing business? ¨ Yes ¨ No If yes, you must provide complete ownership information for the prior owner in column A and ownership information for the new owner in column B.

6.If this is a partial sale, transfer, or conveyance of an existing business (i.e., sale of one or more plants 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? ¨ Yes ¨ No If not, specify the entities with which it was combined:

_________________________________________________________________________________________________________________________________

ERM-14 (Rev. 12/03)

Page 2 of 4

© 2002 National Council on Compensation Insurance, Inc.

Oct 2003 (1)

 

 

APPENDIX

Experience Rating Plan Manual—2003 Edition

A3

 

 

 

7.

Did the legal status of this entity change? ¨ Yes ¨ No

 

 

If yes, you must complete the Type of Entity portion for each entity to reflect such change.

 

8.

Is this transaction a result of bankruptcy? ¨ Yes ¨ No

 

 

If yes, please indicate under which Chapter the bankruptcy was filed. ___________________

 

Corporations—List all names of owners of 5% or more of voting stock and number of shares owned. Submit shareholder proposal if transaction involved exchange of stock.

Partnerships—List each partner and appropriate share in the profits. If the entity is a limited partnership, list name(s) of each general partner(s).

Other—If no voting stock, list members of board of directors or comparable governing body.

Information

 

Column A

 

Column B

 

Column C

 

 

 

 

 

 

Enter name used in Section A for Entity 3

 

 

Enter name used in

 

Enter name used in

 

Entity 3

 

 

Section A for Entity 1

 

Section A for Entity 2

 

If applicable, use this column for multiple

 

 

Entity 1

 

Entity 2

 

 

 

 

 

combinations or entities resulting from mergers

 

 

 

 

 

 

 

 

 

 

 

 

and consolidations

 

 

 

 

 

 

 

Name of Entity

 

 

 

 

 

 

 

 

 

 

 

 

 

Ownership

 

 

 

 

 

 

See reference above

 

 

 

 

 

 

to ownership

 

 

 

 

 

 

information required

 

 

 

 

 

 

for corporations,

 

 

 

 

 

 

partnerships, and

 

 

 

 

 

 

other entities.

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Ownership

 

 

 

 

 

 

Interest or Number

 

 

 

 

 

 

of Shares

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If your business has changed significantly to result in a change to the primary (governing) classification and the process and hazard of the operation have also changed, contact your agent, insurance company or rating organization for additional information.

Section C—Additional Information

Please include any additional information you believe pertinent to the transaction detailed above that cannot be expressed due to the format of this form. If there is not enough space below, attach the information on the entity’s letterhead, signed by an owner, partner, or executive officer.

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

ERM-14 (Rev. 12/03)

Page 3 of 4

© 2002 National Council on Compensation Insurance, Inc.

Oct 2003 (1)

APPENDIX

 

A4

Experience Rating Plan Manual—2003 Edition

Section D—Did You Remember to . . .

Indicate the type of transaction, check all that apply, and include transaction and notification dates?

Complete all necessary entity information? Note: You can use more forms if the number of entities exceeds three.

Entity name

Risk identification number (if you know it)

Federal Employer Identification Number (FEIN)

Type of entity

Primary address, telephone, and other contact information

Mailing address and additional locations if applicable

Fill out the ownership table completely?

Include the names of the entities as listed in Section A?

Include all owners, partners, board of director members, members and/or manager of LLCs, general partners of LPs, or any other comparable governing body?

Include percentage of ownership for each owner, partner, board of director member, member and/or manager of LLCs, general partner of LPs, or any other comparable governing body?

Answer questions 1 though 8?

Section E—Certification

This is to certify that the information contained on this form is complete and correct.

All forms will be returned if this Certification Section is incomplete.

Name of person completing form:__________________________________________________________________________

Check which entity or entities the signer represents:

¨ Entity 1 ¨ Entity 2 ¨ Entity 3 ¨ Other ____________________

__________________________________________

______________________________________

_____________________________________

Signature of Owner, Partner, Member, or

Title

 

Carrier

Executive Officer

 

 

 

__________________________________________

______________________________________

_____________________________________

Print name of above signature

Date

 

Carrier Address

Section F—For Rating Organization Use Only

Associate/automated

Date received

Date complete

Assessment—form complete? What is missing?

Ruling

Revisions necessary—Yes/No

Revisions complete and mailed—Yes/No/NA

Rating Effective Date impacted—Yes/No—if Yes, which ones?

Risk ID impacted—list all impacted, any deactivated? Indicate deactivated #s

All carriers/rating organizations notified?

ERM-14 (Rev. 12/03)

Page 4 of 4

© 2002 National Council on Compensation Insurance, Inc.

Oct 2003 (1)

How to Edit Erm 14 Form

It shouldn’t be challenging to get erm 14 form with the help of our PDF editor. Here's how one could successfully prepare your form.

Step 1: Choose the orange "Get Form Now" button on the following page.

Step 2: You will find all of the options that you can use on your template after you have entered the erm 14 form editing page.

To be able to prepare the form, enter the details the program will request you to for each of the next parts:

erm 14 work comp form empty spaces to complete

Include the asked details in the Type of Transaction Columns A, ENTITY 1—Complete Column A on Page, Complete Name of Entity (including, Risk ID, FEIN, Eff, Policy #, Type of Entity (check all that, ¤ Limited Liability Corporation, ¤ Municipality, ¤ Temporary Labor Service ¤ School, ¤ Religious Organization ¤, ¤ For Profit ¤ Not for Profit ¤, ¤ Franchise, Primary Address, Street, City, Telephone Number, Fax Number, and E-mail Address section.

stage 2 to entering details in erm 14 work comp form

Write down any information you may need within the space Contact Name, Mailing Address (if different than, Additional Location(s) ERM-14, © 2002 National Council on, Page 1 of 4, Web Site, and Oct 2003 (1).

Entering details in erm 14 work comp form step 3

The ENTITY 2—Complete Column B on Page, Complete Name of Entity (including, Risk ID, FEIN, Eff, Type of Entity (check all that, ¤ Limited Liability Corporation, ¤ Municipality, Policy #, ¤ Temporary Labor Service ¤ School, ¤ Religious Organization ¤, ¤ For Profit ¤ Not for Profit ¤, ¤ Franchise, Primary Address, Street, City, Telephone Number, Fax Number, E-mail Address, Contact Name, Mailing Address (if different than, Additional Location(s), ENTITY 3—Complete Column C on Page, Complete Name of Entity (including, and Web Site area is going to be place to insert the rights and obligations of both sides.

Filling in erm 14 work comp form stage 4

Finalize by checking the next fields and preparing them as required: Risk ID, FEIN, Eff, Type of Entity (check all that, ¤ Limited Liability Corporation, ¤ Municipality, Policy #, ¤ Temporary Labor Service ¤ School, ¤ Religious Organization ¤, ¤ For Profit ¤ Not for Profit ¤, ¤ Franchise, Primary Address, Street, Telephone Number, Contact Name, Fax Number, E-mail Address, City, Web Site, Mailing Address (if different than, Additional Location(s), and Section B—Ownership.

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