State of New York WORKERS ' COMPENSATION BOARD STOCKHOLDER OF CORPORATION APPLYING FOR LICENSE TO RE 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the applicant corporation in the designated field. Ensure accuracy as this is crucial for identification.
3. Next, fill in the stockholder's name and address. This information is essential for correspondence and verification purposes.
4. Provide the stockholder's Social Security Number and Federal Employer ID Number. If you do not have these numbers, include a brief explanation in the provided space.
5. Indicate the percentage of stock owned by the stockholder. This helps establish ownership and control within the corporation.
6. Answer whether there have been any criminal convictions or pending charges against you or your corporation. If applicable, provide details in the space provided.
7. Respond to questions regarding ownership of stock in corporations with self-insurer status or those authorized to write workers' compensation insurance in New York State, providing details if necessary.
8. Finally, ensure that the application is signed by either the stockholder or chief executive officer of the parent corporation, attaching any required corporate resolutions if needed.

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