Mack, Mack & Waltz Group

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ERM 14 Confidential Request for Change

Use this form to facilitate changes to your Workers Compensation policy regarding amendments to your business ownership.

E-mail Address: *
Name change only
Combination of separate entities
Sale, transfer or conveyance of ownership interest
Merger or consolidation
Formation of a new entity
Sale, transfer or conveyance of an entitys physical assets to another entity which takes over its operations
Voluntary or court-mandated establishment of a trustee or receiver, excluding a debtor in possession, a trustee under a revocation trust or franchisor
Total Income & Expenses
Name
Street Address
City
State
Zip
Legal Status of Entity
Ownership
Total shares of voting stock
Date of Ownership Change, Acquisition, or Combinability
Carrier, Policy Number and Effective Date
Experience Rating ID Number (Carrier use only)
1. Has this entity operated under another name in the last four years?	Yes No
2. Is the entity currently related through common majority ownership to any entity not listed on the front of the form?	Yes No
3. Has this entity been previously related through common majority ownership to any other entities in the last four years?	Yes No
If you answered yes to 1, 2, or 3 above, please provide the following information
Name of Business
Principal Location
Carrier and Policy Number
Effective Date
4. Were the assets and/or ownership interest (all or a portion) of this entity aquired from a previously existing business?	Yes No
If yes, you must provide complete ownership information on the prior owner in Column A and ownership information on the new owner in Column B above.
5. If this is a partial sale, transfer, or conveyance of an existing business (i.e., sale of one or more plants or locations):
a. Explain what portion or location of the entire opertaion was sold, transfered, or conveyed.
b. Was this enity insured under a separate policy from the remaining portion? Yes No If not, specify the entities with which it was combined	Yes No
6. If this entity has operations in Delaware or Pennsylvania, provide the number of employees from each of these states retained from the prior ownership
Indicate the percentage or number retained out of the total from each of these states
This is to certify that the information contained above is complete and correct.
Name of Insured
Name of person completing the form
Date this ownership change was reported in writing to your insurance carrier
Owner, Partner or Executive Officer
Title
Carrier
Carrier Address
Email
Date
Additional Comments
Please give any additional comments about the coverage you desire:

Verification Code:
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