Request For Information - Service Lloyds
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1
2TEXAS 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
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