Form Lb-0441 - Report To Determine Status - Application For Employer Number - 2016 Page 2

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11. (A) Name and Address of predecessor employer
________________________________________________
________________________________________________
________________________________________________
(B) Account Number of predecessor employer ______________________
(C) Date of acquisition ___________________
(D) Did you acquire all of your predecessor’s business in Tennessee? YES
NO
If No, what percentage did you acquire? _________
(E) Did your predecessor continue in business in Tennessee?
YES
NO
(F) Tennessee Employment Security Law provides for the mandatory transfer of an employer’s benefit and premium experience whenever there is any
common ownership, management or control between the predecessor and successor employers.
Did any owner or manager of this company have an ownership interest in or participate in the management or control of the
business acquired?
YES
NO
If “YES,” please explain: _____________________________________________________________________________________
Per TCA 50-7-403(b)(2)(C)(ii) “Common ownership, management or control” includes any individual who has at least a 10% ownership interest in -
or who participates in the management or control of - the predecessor’s trade or business and has a relative with a 10% ownership interest in - or who
participates in the management or control of - the successor’s trade or business.
Does anyone who had a 10% or more ownership interest in the previous company - or who participated in its management or control -
have a relative with a 10% or more interest in this company or who participates in its management or control?
YES
NO
If “YES,” please explain: ____________________________________________________________________
If you are not subject to a mandatory transfer of experience but wish to succeed to the experience of the predecessor employer, Form LB-0483,
Application for Transfer of Experience Rating Record, must be submitted by no later than the end of the quarter following the quarter in which the
acquisition occurred.
12. Enter below the amount of total payroll for each quarter in which you have had or expect to have employment.
YEAR
JAN-MAR
APR-JUNE
JUL-SEPT
OCT-DEC
YEAR
JAN-MAR
APR-JUNE
JUL-SEPT
OCT-DEC
13. FAILURE TO PROPERLY COMPLETE THIS SECTION WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.
(A) Describe the major business activity of the account to be covered, listing any products manufactured or sold, or service provided.
Be as descriptive as possible. ________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
(B) In what Tennessee County is your company located? ________________________________________________________
(If account covers sales reps or other personnel working from home, list county or city of residence.)
(C) Is the primary purpose of the employee(s) covered by this application to support other locations of your company? YES
NO
If YES, then check the category that best applies. Add comments as necessary.
HEADQUARTERS (e.g., corporate or regional management offices) _________________________________________________
ADMINISTRATIVE (e.g., bookkeeping, accounting, payroll, HR, PR) ________________________________________________
WAREHOUSING (e.g., storage, distribution, equipment yard) _____________________________________________________
SALESMAN (indicate product) ____________________________________________________________________________
INFORMATION TECHNOLOGY (e.g., software publication, programming, systems design, data processing) _________________
OTHER (e.g., repair shop, security office, maintenance, employee recreation facility) ____________________________________
(D) Below are some industries that often need additional clarification. This section may not apply to every employer. If you see your
industry, please answer the corresponding question(s).
Construction:
What type of construction? __________________________________
residential or
non-residential?
Mostly
Property Mgmt.:
Does this business manage property for
others or for
itself?
Mostly
residential or
non-residential?
Trucking:
Is the main trucking activity
local or
long distance?
truckload or
less than truckload?
Mostly
Empl. Agency:
Is this a
Temporary Staffing Service or an
Employment Placement Agency?
Health Care:
Is this a
Doctor’s Office,
Multi-Disciplinary Clinic,
Freestanding Urgent Care Center or
Other?
Please specify. ______________________________________________________________________________________________
Info Tech (IT):
Which category best fits your business?
Software Publication,
Programming,
Systems Design,
Data Processing
Restaurant:
Is the restaurant
Full Service,
Fast Food,
Cafeteria/Buffet,
Snack Bar,
Other? Please specify. _____________________
Consulting:
What is the primary type of consulting?
Administrative,
Human Resources,
Marketing,
Process/Logistics,
Environmental, or
Other - Please specify. _____________________________________________________________________
Home Health:
Does the care involve skilled nursing?
YES
NO
Retail:
What is the primary product? ___________________________________________________________________________________
Wholesale:
What is the primary product? ___________________________________________________________________________________
Mining:
What is the primary product? ___________________________________________________________________________________
Convenience Store: Does the store sell gasoline?
YES
NO
Manufacturing:
What is the primary product? ___________________________________________________________________________________
LB-0441 (Rev. 9
)
Page 2
RDA 1559

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