Step 1 - Contact Info
Step 2 - Select Purpose
Step 3 - Entities / Owners
Step 4 - Attach Documents
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 20 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 email@example.com for additional information.
Contact Information of the person submitting this form
Relationship to Business:
This change is being submitted by:
Name of owner/officer who authorized you to submit this change on their behalf:
Email address of owner/officer who authorized you to submit this change on their behalf:
A copy of the PDF created by this submission will be emailed to both the authorized representative submitting the change and the owner/officer who gave authorization.
BEGIN OWNERSHIP CHANGE »