Request For Information - Service Lloyds (Page 2 of 2) in pdf

Request For Information - Service Lloyds Page 2

REQUEST FOR INFORMATION

Has this entity operated under another name in the last four years? _________

Is the entity currently related through common majority ownership to any entity not listed on the front of the form?

_________

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

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.

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.

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

Request For Information - Service Lloyds Page 2