Texas Wc Rfi Details

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.

QuestionAnswer
Form NameWc Rfi Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namestx wc form, texas leosa forms, texas wc rfi, tx wc exclusion form

Form Preview Example

TEXAS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY MANUAL

WC-RFI

1st Reprint

Effective May 1, 1994

 

 

 

 

 

REQUEST FOR INFORMATION

 

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

 

 

necessary).

 

_____ 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.

INFORMATION

A

B

C

 

Name and street address of Entity

 

 

 

 

(P. O. Box Numbers are not

 

 

 

 

acceptable)

 

 

 

 

Legal Status of Entity (Corporation,

 

 

 

 

Partnership, Sole Proprietor,

 

 

 

 

Trustee, Receiver, Limited

 

 

 

 

Partnership, etc.)

 

 

 

 

Ownership

 

 

 

 

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

 

 

 

 

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?

_________

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

Principal

Carrier and

Effective

Business

Location

Policy Number

Date

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Title

Executive Officer

 

 

 

 

 

Print name of above signature

 

Date

WC-RFI