Blank Erm 14 Template

The ERM-14 form is a confidential document used to request vital ownership information necessary for calculating premiums related to workers' compensation insurance policies. It is essential for policyholders to report any ownership changes within 90 days to avoid potential delays in processing. Accurate and complete submissions are critical; thus, employers should fill out the form carefully to ensure compliance.

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Article Guide

The ERM-14 form is a crucial tool for businesses seeking to maintain compliant workers' compensation insurance policies. This confidential document assists employers in providing detailed ownership information required for accurately calculating their insurance premiums. Timely reporting of ownership changes is essential, as policies mandate that such updates must be made in writing to the insurance carrier within a 90-day window following any change. The form outlines specific transaction types that must be reported, including changes in the legal entity's name, the sale or transfer of ownership interests, mergers, and the formation of new entities. Additionally, if ownership changes involve trusts or the determination of combinability with other entities, this must also be documented. Failure to submit complete information or the required signature may result in processing delays, which could impede the employer's ability to secure necessary coverage. Importantly, the form also allows for ownership information to be submitted via narrative form on the employer's letterhead, provided that it is signed by an authorized individual, such as an owner or executive officer. This flexibility facilitates the accurate and swift communication of vital ownership details, ensuring that businesses remain insulated from potential liabilities associated with insurance noncompliance.

Form Sample

REQUEST FOR OWNERSHIP INFORMATION—ERM-14 FORM

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 # _____________________________ Email Address ________________________________________________

Relationship to business entity reporting ownership information _______________________________________________

Section B—Transaction Information

Type of Transaction (check all that apply)	Transaction
	Effective Date

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)

Has dissolved

Is nonoperative

May continue to operate in a limited capacity

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(s)

Include a brief description of the transaction(s) selected above. Attach additional information on the employer’s letterhead, if needed.

–If this is a partial sale, transfer, or conveyance of an existing business (e.g., sale of one or more plants or locations), explain what portion or location of the entire operation was sold, transferred, or conveyed.

–If any of the entities that underwent a change in ownership were related through common ownership to any other entity before the transaction described above, list the entities and their current owners’ names and percentages of ownership below.

ERM-14 (Rev. 2/20)

Page 1 of 2

Section D—Business Entity Information

Copies of this page may be submitted for transactions with more than three entities.

		Entity 1	Entity 2	Entity 3
		Entity before the change or	Entity after the change or	Entity after a merger or
	Entity Information	to determine combinability	to determine combinability	consolidation or to determine
		with another entity	with another entity	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.

_________________________________________________	_________________________	________________________________
Signature of Owner, Partner, Member, or Executive Officer Title		Business Name
_________________________________________________	_________________________
Print name of above signature	Date

ERM-14 (Rev. 2/20)

Page 2 of 2

⇩ PDF

Document Specifications

Fact Name	Details
Purpose	The ERM-14 Form is designed to gather ownership information for calculating workers' compensation insurance premiums.
Reporting Requirement	Any changes in ownership must be reported to the insurance carrier in writing within 90 days.
Contact Information	Section A of the form collects contact info, including the name of the person filling it out, their role, and their contact details.
Transaction Types	The form allows for multiple types of transactions such as sales, mergers, and ownership changes to be noted.
Description of Transactions	Section C requires a brief description of selected transactions and may require additional information on employer letterhead.
Business Entity Information	Section D collects key details about each business entity involved in the transaction, like name, address, and ownership structure.
Certification Requirement	Section E requires a signature from an owner or executive confirming the completeness and correctness of the information provided.
State-Specific Laws	Forms may vary by state; it’s vital to refer to local regulations governing workers’ compensation and ownership reporting.

Steps to Filling Out Erm 14

After completing the ERM-14 Form, submit it to your insurance carrier. This helps ensure that your workers' compensation policy reflects any ownership changes accurately. Be sure that all sections are filled out completely to avoid delays in processing.

Contact Information: Write the name of the person completing the form, the employer's name, a phone number, an email address, and the relationship to the business entity.
Transaction Information: Check all applicable transaction types, noting the effective date for each transaction selected.
Description of Transaction(s): Provide a brief explanation of the selected transaction(s). If needed, attach additional information on the employer's letterhead.
Business Entity Information: Fill out three sections (Entity 1, Entity 2, Entity 3) with the necessary details about the business entities involved, including their name, address, legal status, ownership details, FEIN, Risk ID Number, Policy Number, and Policy Effective Date.
Certification: The owner, partner, member, or executive officer must sign the form, indicate their title, print their name, and date the form.

More About Erm 14

What is the purpose of the ERM-14 form?

The ERM-14 form is designed to collect ownership information necessary for calculating the premium for a workers' compensation insurance policy. It is important for policyholders to keep their insurance carrier updated about any changes in ownership or other relevant details within 90 days of such changes.

Who needs to fill out the ERM-14 form?

The form should be completed by someone who is closely associated with the business, such as an owner, partner, member, or executive officer. Providing accurate information is crucial to ensure proper processing and compliance with insurance requirements.

What types of ownership transactions need to be reported?

The ERM-14 form requires reporting several types of transactions. These include changes in the legal name or status of the entity, sales or transfers of ownership interests, asset sales, mergers, the formation of new entities, and changes involving trusts or receiverships. Each transaction type has specific details you need to provide when completing the form.

What should I include in the transaction description section?

In the section for describing the transaction(s), give a brief overview of the ownership changes or transfers that occurred. If applicable, specify whether the change involved a partial sale and detail the specific parts of the business affected. You may add additional information on your company's letterhead if needed.

Can I submit additional documents along with the ERM-14 form?

Yes, you can include additional documents or details as necessary. If you have more than three entities to report, you may copy the form's pages and use the employer's letterhead for a more organized presentation of your information.

What happens if the form is incomplete?

Providing incomplete information or failing to include a required signature may lead to delays in processing the form. It is essential to review the form carefully before submission to avoid any setbacks with your insurance policy.

What if I need assistance while filling out the ERM-14 form?

If you have questions about how to fill out the ERM-14 form, you can reach out to your insurance agent, insurance company, or the relevant rating organization for guidance. They can provide you with the necessary assistance to complete the form accurately.

Do I need to report a DBA name change?

No, a "Doing Business As" (DBA) name change does not require reporting on the ERM-14 form. The form focuses on more significant changes to the legal status of the business entity.

What is the certification section for?

The certification section at the end of the form is where the person completing it can attest to the accuracy and completeness of the information provided. This section must be signed and dated by an authorized individual, ensuring accountability in the reporting of ownership changes.

Common mistakes

Failing to provide complete contact information. It’s critical to fill out all sections, including your name, phone number, and email address, to ensure effective communication.
Neglecting to report ownership changes within the 90-day timeframe. Missing this deadline can lead to complications with your workers' compensation insurance.
Overlooking the need for a signature. An unsigned form is considered incomplete and will result in delays during processing.
Using DBA names where legal name changes are required. Remember that doing business as names do not substitute for the actual legal entity name changes.
Failure to check all applicable transaction types. It's important to select all options that describe the ownership change to provide a clear picture of the transaction.
Providing vague descriptions of transactions. Clear, concise explanations help in understanding the context of the ownership change.
Disregarding the need for a summary of owners and percentages. Ownership lists should total 100%, and this detail ensures transparency.
Incompleteness in describing associated entities. If related entities were involved, detailing their owners and ownership percentages is crucial.
Failing to provide additional documentation when needed. Attaching extra information on letterhead clarifies complex transactions.
Not verifying information before submission. Rushing through the process may lead to errors that could complicate the insurance premium calculation.

Documents used along the form

The ERM-14 Form is essential for updating ownership information related to a workers' compensation insurance policy. It helps insurers calculate premiums accurately. In addition to the ERM-14, there are several other forms and documents that may be required during various transactions involving changes in business ownership. Below is a brief overview of these documents.

Insurance Policy Change Request Form: This form allows the business to formally request changes to its existing insurance policy, whether it's related to coverage limits, endorsements, or other adjustments based on ownership changes.
Business Ownership Transfer Agreement: This document outlines the terms of ownership transfer from one party to another. It typically includes details such as purchase price, payment terms, and conditions that must be met for the transfer to occur.
Articles of Incorporation or Organization: This document is necessary for businesses that are registering a new entity or making changes to an existing company’s structure. It includes information like the business name, purpose, and ownership structure.
Operating Agreement: For LLCs (Limited Liability Companies), an operating agreement delineates the roles, responsibilities, and ownership percentages of the stakeholders within the company. It also outlines how decisions are made.
Corporate Bylaws: This document establishes the rules governing the management of a corporation. It typically includes information regarding the appointment of directors, voting procedures, and meetings.
Certificate of Good Standing: This certificate verifies that a company is legally permitted to operate within its state of incorporation. It is often required when changes in ownership or structure occur.
Tax Forms (such as IRS Form 2553): Depending on the nature of the business structure and changes made, various tax forms may need to be completed to reflect ownership changes for tax purposes.
Resolutions of the Board of Directors: If the business is a corporation, formal resolutions may be required to document the board's approval for ownership or structural changes. This provides legal backing for the alterations made.

Understanding these forms and their purposes is crucial during ownership transitions. Each document plays a significant role in ensuring compliance, maintaining accurate records, and protecting all parties involved in any changes pertaining to a business entity.

Similar forms

The ERM-14 form serves a specific purpose in tracking ownership changes for a business, similar to a Change of Ownership form. This document is often required when ownership of a business entity transitions from one party to another. It collects essential details such as the names of the new owners and the nature of the change. Just like the ERM-14, the Change of Ownership form is important for insurance purposes, as it helps ensure that polices are accurately adjusted according to the new ownership structure.

Another document that parallels the ERM-14 form is the Business License Application. When a business undergoes a change in ownership, a new business license may be required to reflect the name or ownership of the entity. This application collects details about the business's structure and ownership, akin to how the ERM-14 gathers ownership information for insurance calculations. Both documents are crucial for ensuring compliance with local regulations and maintaining accurate records.

The Articles of Incorporation also share similarities with the ERM-14 form. When a business entity is formed or experiences significant ownership changes, the Articles must be filed with the Secretary of State. This document outlines key information about the company, including its name, purpose, and ownership structure. Just as the ERM-14 captures recent ownership changes necessary for insurance, the Articles provide foundational information that is critical for legal recognition of the business.

A Partnership Agreement can be viewed as another document that reflects changes similar to those documented on the ERM-14 form. In cases where a business operates as a partnership, any changes to the partners or their ownership stakes must be documented in this agreement. This helps clarify responsibilities and ensures compliance with internal and external regulations. The ERM-14 works similarly by capturing ownership details affecting workers' compensation policies.

Lastly, the Membership Certificate for Limited Liability Companies (LLCs) serves a comparable function. When there are changes in ownership of an LLC, a new Membership Certificate might be issued to reflect new members and their ownership percentages. Like the ERM-14, this certificate provides essential information about who holds an interest in the business, ensuring clarity for partners and insurers alike. Both documents are therefore central to reflecting accurate ownership status in official records.

Dos and Don'ts

When filling out the ERM-14 form, consider the following guidelines:

Provide complete and accurate information in all sections.
Ensure the form is signed by an authorized person, such as an owner or executive officer.
Submit the form within 90 days of any ownership changes.
Attach additional details on the employer's letterhead if more information is needed regarding the transaction.

Conversely, avoid the following mistakes:

Do not leave any required fields blank; incomplete forms may cause processing delays.
Avoid using DBA names for reporting changes, as they are not necessary.
Do not submit the form without ensuring all signatures are included.
Do not wait beyond the 90-day reporting window to submit changes.

Misconceptions

Misconception 1: The ERM-14 form is only for large businesses.

This form is designed for any business, regardless of size. Small businesses also need to report ownership changes.

Misconception 2: Only the business owner can complete the ERM-14 form.

While the owner is typically responsible, anyone with an appropriate relationship to the business, such as a partner or executive officer, can fill it out.

Misconception 3: DBA name changes require submitting the ERM-14 form.

Changes to a "doing business as" (DBA) name do not necessitate filing the ERM-14 form. Only legal name changes must be reported.

Misconception 4: You have unlimited time to report changes.

Changes must be reported to your insurance carrier within 90 days. Delays may have serious consequences.

Misconception 5: The ERM-14 form is optional.

Filing this form is a requirement. Not submitting it could lead to complications in your workers' compensation coverage.

Misconception 6: Incomplete forms can be submitted without penalties.

Incomplete forms can result in processing delays. It's important to provide all requested information.

Misconception 7: You cannot provide ownership information in a narrative form.

Ownership information can be submitted in narrative form on your company's letterhead, with proper signatures.

Misconception 8: Only certain types of transactions need to be reported.

All specified types of transactions, including mergers and asset transfers, must be reported as outlined in the form.

Misconception 9: Errors on the form can be corrected after submission without issue.

Errors should be corrected before submission to avoid delays in processing. Once submitted, corrections may require additional follow-up.

Misconception 10: The ERM-14 form does not require a signature.

A signature from an owner, partner, member, or executive officer is essential for validating the information on the form.

Key takeaways

Purpose: The ERM-14 form is used to collect ownership information essential for calculating workers' compensation insurance premiums.
Timely Reporting: Report any ownership changes to your insurance carrier in writing within 90 days of the change to avoid complications.
Contact Information: Complete the contact information section accurately, including the name, employer, phone number, email address, and relationship to the business.
Transaction Types: Indicate all relevant transaction types, such as mergers, sales, or name changes. Only certain changes need to be reported.
Description of Transactions: Provide a brief description of changes selected in Section B, and include additional documentation if necessary.
Ownership Details: List individual owners and their ownership percentages accurately; ownership must total 100% on the form.
Certification: Ensure the form is signed by an authorized individual, such as an owner or executive officer, to validate the information provided.
Additional Entities: If reporting on multiple entities, use additional copies of the required sections to ensure all entities are covered.