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New york stockholder form

New york stockholder form 2026

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The document is a form from the New York Workers' Compensation Board for stockholders of corporations applying for a license to represent self-insurers under specific sections of the Workers' Compensation Law. It requires information about the applicant corporation, stockholder details, ownership percentages, and any criminal history. Additionally, it includes privacy notifications regarding the collection of personal information and verification forms for both individual and corporate stockholders.

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Click ‘Get Form’ to open the New York Stockholder Form in our editor.
Begin by entering the name of the applicant corporation in the designated field. Ensure accuracy as this is crucial for identification.
Next, fill in the stockholder's name and address. This information is essential for correspondence and verification purposes.
Provide the stockholder's Social Security Number and Federal Employer ID Number. If you do not have these numbers, explain why in the provided space.
Indicate the percentage of stock owned by the stockholder. This helps clarify ownership stakes within the corporation.
Answer questions regarding any past criminal convictions or pending charges. Be honest, as this information is vital for compliance.
Finally, sign the form at the bottom. If applicable, ensure that a corporate resolution is attached if someone other than the CEO signs.

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