EXHIBIT C
INTERSTATE EXPERIENCE RATING
CONFIDENTIAL REQUEST FOR INFORMATION

The following confidential ownership statements may be used in establishing premiums for your insurance coverages. It is extremely important that all questions be answered completely. Your workers compensation 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. Submit the completed form to the rating organization.
Purpose

Name Change only
Complete column A for former entity and column for newly named entity
Complete only questions 1,2 and 3 on Section 2
Combination of separate entities
Complete a separate column for each entity related through common ownership (attach additional forms if necessary)
Sale, transfer or conveyance of ownership interest
Complete column A for ownership before the change and column B for ownership after the change
Merger or consolidation
{ attach copy of agreement)
Complete columns A and B for the former entities and column C for the surviving entity
Formation of a new entity
Complete column A
Sale, transfer or conveyance of an entity’s physical assets to another entity which takes over its operations
Complete column A for the former entity and column B for the acquiring entity
Voluntary or court-mandated establishment of a trustee or receiver, excluding a debtor in possession, a trustee under a revocable trust or a franchisor
Complete column A for ownership prior to the change, and column B for the trustee or receiver established
INFORMATION A B C
Name and street address of entity
  (P.O. Box Numbers are not acceptable)
Legal Status of Entity
  (Corporation, Partnership, Sole Proprietor, Trustee)
Ownership
  Corporations:
List names of owners of 5% or more of voting stock and number of shares owned. *(Submit
shareholder proposal if transaction involved exchange of stock).
Partnerships:
List each general
partner and appropriate share in the profits. (If limited partnership, list
name of general partner.
Other:
If no voting stock, list members of board of directors or comparable governing body.
SECTION 2
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 & Policy Number Effective Date
4. Were the assets and/or ownership interest (all or a portion) of this entity acquired from a previously existing business?
 Yes
No
 

If yes, you must provide complete ownership information of the prior owner in column
A and ownership information on the new owner in column B on the Page 1 of this form.
5. If this is a partial sale, transfer, or conveyance of an existing business (i.e., sale of one or more plants or locations):
5a. Explain what portion or location of the entire operation was sold, transferred, or conveyed.
5b. Was this entity insured under a separate policy from the remaining portion? Yes
No
  If not, specify the entities with which it was combined:
  If this entity has operations in Delaware or Pennsylvania, provide the number of employees from each of these states retained from the prior ownership out of
  Indicate the percentage or number retained out of the total from each of these states % state

NOTE:
If your business has changed significantly to result in a change to the primary (governing) classification and the process and hazard of the operation have also changed, contact your agent, insurance company, or rating organization for additiona information.

This is to certify that the information contained on this form is complete and correct.
  Name of insured
  Name of person completing form
  Date this ownership change was reported in writing to your insurance carrier
  Name of Owner, Partner or Executive
  Title
  Carrier
  Name of Carrier officer
  Carrier address
  Date
     
I have read and agree with the terms above.
I agree.
  Your e-mail address
  Your comments