Form Application And Agreement For Partial Transfer Of Experience Rating Record - Louisiana Department Of Labor Page 2

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State of Louisiana
Department of Labor
Post Office Box 94186
Baton Rouge, LA 70804-9186
PARTIAL TRANSFER OF EXPERIENCE RATING RECORD
(Supplement to Application & Agreement)
Enter in Item 3 the names and social security numbers of all employees on the payroll of the transferred portion of the
business as of the date of transfer shown in Item 3 on the reverse side of this form.
KEEP COPY FOR YOUR RECORDS
1. Successor Employer Name: ____________________________________ Account No. _____________
2. Predecessor Employer Name: __________________________________ Account No. _____________
3. List of employees of transferred portion:
Social Security Number
Name
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
_________________________
_______________________________________
Rev. (1/03)
Page 2 of 2

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