Wc Rfi Form PDF Details

In navigating the complexities of workers' compensation insurance, the WC-RFI form emerges as a pivotal document, particularly within Texas. Drafted to streamline the process of establishing premiums under the Experience Rating Plan, this form mandates thorough responses to a series of probes regarding ownership changes, mergers, or operational shifts that might influence insurance rates. Its implementation since May 1, 1994, underscores the rigorous efforts to maintain transparency and accuracy in the insurance domain. By categorizing requests into distinctive purposes such as name changes, entity combinations, ownership transfers, mergers, formations of new entities, or the sale of physical assets, the form ensures comprehensive coverage of scenarios that affect premium calculations. It goes further to demand detailed information on entity ownership, legal status, and changes therein, alongside specifics on any operational transformations that could alter classification for insurance purposes. The completion and submission of this form, as directed to one's insurance company, not only facilitates the accurate assessment of insurance premiums but also serves as a means of certifying the veracity of the information provided, underscoring the form's role as a vital instrument in the orchestration of fair and precise workers' compensation coverage.

Form NameWc Rfi Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namestexas wc officer exclusion form, texas leosa forms, wc owner exclusion form texas, rfi online

Form Preview Example



1st Reprint

Effective May 1, 1994








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,


contact your agent or your insurance company. Submit the completed form to your insurance company.






PURPOSE (Check One)



Name change only



Complete column A for former name and column B for new name.



Complete only questions 1, 2 and 3 on page 2.


_____ Combination of separate entities



Complete a separate column for each entity related through common ownership (attach additional forms if





_____ Sale, transfer or conveyance of ownership interest



Complete column A for ownership before the change and column B for ownership after the change.



Merger or consolidation



Complete columns A and B for the former entities and column C for the surviving entity.


_____ Formation of a new entity



Complete column A.


_____ 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.






Name and street address of Entity





(P. O. Box Numbers are not










Legal Status of Entity (Corporation,





Partnership, Sole Proprietor,





Trustee, Receiver, Limited





Partnership, etc.)










Corporations--List names of





owners of 100% voting stock and





number of shares owned.* (Submit





shareholder proposal if transaction





involved exchange of stock.)





Partnerships--List each general





partner and appropriate share in





the profits. (If limited partnership,





list name of general partner.)





Other--If no voting stock, list





members, board of directors or





comparable governing body.





* Total shares of voting stock issued





Date of Ownership Change,








Acquisition, or Combinability





Insuring Company, Policy Number





and Effective Date







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?


3.Has this entity been previously related through common majority ownership to any other entities in the last four years?


If you answered yes to 1, 2, or 3 above, please provide the following information:

Name of


Carrier and




Policy Number














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?


If not, specify the


entities with which it was combined:








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



Executive Officer






Print name of above signature




How to Edit Wc Rfi Form Online for Free

You can certainly complete documents through our PDF editor. Editing the officers exclusion form for texas file is effortless in case you try out the next steps:

Step 1: To get going, select the orange button "Get Form Now".

Step 2: Now it's easy to manage your officers exclusion form for texas. This multifunctional toolbar allows you to include, remove, transform, and highlight text or perform other sorts of commands.

Enter the requested details in every single part to create the PDF officers exclusion form for texas

step 1 to writing tx wc exclusion form

Inside the segment INFORMATION Name and street, owners of voting stock and number, PartnershipsList each general, OtherIf no voting stock list, members board of directors or, and Total shares of voting stock type in the information that the application asks you to do.

step 2 to finishing tx wc exclusion form

Within the section dealing with Has this entity operated under, REQUEST FOR INFORMATION, Is the entity currently related, Has this entity been previously, If you answered yes to or above, Name of Business, Principal Location, Carrier and Policy Number, Effective Date, Were the assets andor ownership, and If yes you must provide complete, it's important to put down some significant data.

tx wc exclusion form Has this entity operated under, REQUEST FOR INFORMATION, Is the entity currently related, Has this entity been previously, If you answered yes to   or  above, Name of Business, Principal Location, Carrier and Policy Number, Effective Date, Were the assets andor ownership, and If yes you must provide complete fields to insert

The If this is a partial sale transfer, a Explain what portion or location, b Was this entity insured under a, If not specify the, entities with which it was combined, c What entities will the seller, This is to certify that the, Name of insured, Name of person completing form, Signature of Owner Partner or, Title, Print name of above signature, and Date field enables you to specify the rights and obligations of both sides.

Entering details in tx wc exclusion form part 4

Step 3: Choose the Done button to ensure that your finalized document could be transferred to any electronic device you select or forwarded to an email you indicate.

Step 4: You could make copies of the form tostay clear of all forthcoming concerns. Don't be concerned, we don't disclose or record your data.

Watch Wc Rfi Form Video Instruction

Please rate Wc Rfi Form

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .