The purpose of this confidential form is to obtain ownership information to assist in calculating premium for your workers compensation insurance policy. Your policy requires that you report ownership changes, and other changes as detailed below, to your insurance carrier in writing within 90 days of the change. If you have questions, contact your agent, insurance company, or the appropriate rating organization. Incomplete information or a missing signature may result in a delay in processing.

The ownership information required on this ERM-14 Form can also be submitted in narrative form on the letterhead of the employer, signed by an owner, partner, member, or executive officer.

Section A - Contact Information

Name of person completing this form:
Your Employer:
Phone # () -
E-mail Address:
Relationship to business entity reporting ownership information:

Section B - Transaction Information

Transaction Effective Date:
 
Type of Transaction (select one)
Name and/or legal entity change
The name and/or legal status of the entity has changed. DBA name changes do not need to be reported.
Sale, transfer, or conveyance of all or a portion of an entity's ownership interest
Complete or partial sale of the business entity's ownership interest.
Sale, transfer, or conveyance of an entity's physical assets to another entity that takes over its operations
An entity's assets have been sold or transferred. The acquiring entity has taken over the operations, and the selling entity retained its legal business name.
Merger or consolidation
Two or more entities have merged or combined to form a single entity.
Formation of a new entity that acts as, or in effect is, a successor to another entity that:
(Select one)
Formation of a new entity
A new entity has formed that is not a successor to another entity. Report this change only to determine combinability with another entity.
An irrevocable trust or receiver, established either voluntarily or by court mandate
A change has occurred to the business, either voluntarily or by court mandate, requiring the entity to be put in a trust or receivership.
Determination of combinability of separate entities
Two or more entities may need to be combined or separated based on their ownership interest.

Section C - Description of Transaction

Include a brief description of the transaction(s) selected above. Attach additional information on the employer's letterhead, if needed.
 
Add attachment
- Attachments must be in Portable Document Format (.pdf).
- Browse for the .pdf document then select 'Attach File'

Section D - Business Entity Information

Copies of this page may be submitted for transactions with more than three entities.
Select the Additional Section D link below to add more than 3 entities.
Additional Section D
Update and save your additional Section D document(s). Use the Add Attachment feature above to include the additional Section D page(s) with this form submission.


Entity Information
Entity 1
Entity before the change or to determine combinability with another entity
Entity 2
Entity after the change or to determine combinability with another entity
Entity 3
Entity after a merger or consolidation or to determine combinability with another entity
1. Name of Business
Provide the legal name of the business entity.
2. Primary Address
(Street, City, State, Zip)
3. Legal Status
(See examples in item 4 below)
4. Ownership
List names of individual owners, partners, etc. and percentages of ownership (if applicable). Ownership should total 100%.
- Sole Proprietorship: Owner
- Corporation: Owner(s) and percentages of ownership
- General Partnership: Partners and percentages of ownership
- Limited Partnership: General partners and percentages of ownership
- Limited Liability Company: Members and percentages of ownership
- Revocable Trust: Grantor(s)
- Irrevocable Trust: Trustee(s)
- Other: If no voting stock, list members of board of directors or comparable governing body
5. FEIN
6. Risk ID Number
7. Policy Number
8. Policy Effective Date
9. Contact Name
10. Contact Phone/Email

Section E - Certification

This is to certify that the information contained on this form is complete and correct.
BY SUBMITTING THIS FORM ERM14 THROUGH THIS WEB SITE AND TYPING MY NAME IN THE BOX BELOW, I AM OFFERING MY DIGITIAL SIGNATURE IN LIEU OF MY HANDWRITTEN SIGNATURE. MY DIGITAL SIGNATURE CERTIFIES THE INFORMATION CONTAINED ON THIS FORM IS COMPLETE AND CORRECT. THE DIGITAL SIGNATURE CONTAINED WITHIN THIS APPLICATION IS ENFORCEABLE AND CANNOT BE DENIED LEGAL EFFECT PURSUANT TO WIS. STAT. 137.15(1).
Signature of Owner, Partner, Member, or Executive Officer:
Title:
Business Name:

ERM-14 (Rev. 2/20)