Did you know that there is a special form required to request a workbench or chair reservation in the library? Well, there is! The Wc Rfi Form can be found on the Circulation Desk's website and must be filled out at least five days before your desired date. Spaces are limited and fill up quickly, so be sure to submit your request as soon as possible! For more information, please visit our website or contact us at 610-758-3254.
You will discover information about the type of form you want to fill out in the table. It can tell you the time it takes to fill out wc rfi form, exactly what fields you will need to fill in, etc.
| Question | Answer |
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| Form Name | Wc Rfi Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | tx wc form, texas leosa forms, texas wc rfi, tx wc exclusion form |
TEXAS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY MANUAL |
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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 |
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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 |
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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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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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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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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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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 |
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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 |