WCRIBMA Request for Ownership Information

All workers’ compensation insurance policies issued to Massachusetts employers require that employers report in writing to the insurance company any changes in ownership within 90 days of the change. This tool will generate the WCRIBMA Request for Ownership Information (ERM Form) that you are required to submit to your insurance company. The information reported on the ERM Form will be used to assist in policy writing and calculating the related employers’ experience ratings and resulting premiums. If any of the entities are interstate rated or doing business in multiple states, the ERM form will also be sent to NCCI for processing.

The Request for Ownership Information, ERM Form, must be completed and submitted in one session. The form cannot be saved and submitted at a later time. If incomplete forms are not submitted or left inactive for 60 minutes or more, it will time out and you must reenter the information in order to submit.

Please contact Customer Services at #617-439-9030 or email customerservices@wcribma.org for additional information.

You hereby certify that you are a legal owner or officer of one of the employers subject to this ownership form (“Employer”) or an authorized representative of one of the employers subject to this ownership form (“Authorized Representative”).

Use of the Manage Ownership Tool is conditional upon your acceptance of and compliance with the terms and conditions set forth here in the
Terms and Conditions for Use of the WCRIBMA Website.

Contact Information of the person submitting this form

* Name:

* Company:

* Title:

* Relationship to Business:

* Phone Number:

( ) -

* Email Address:

* Confirm Email:

Submitter Authorization

* This change is being submitted by: Employer Authorized Representative