New york erm 14 fillable form 2026

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The document provides detailed instructions for completing the ERM-14 form, which is used to report changes in ownership, mergers, consolidations, or combinations of entities for experience rating purposes. It outlines the necessary information required, including entity names, ownership details, and transaction types. The form must be signed by an authorized individual and submitted to the appropriate rating organization within 90 days of any changes. Additionally, it includes guidance on using the PDF format of the form and emphasizes the importance of accuracy in reporting ownership information.

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Click ‘Get Form’ to open the New York ERM 14 fillable form in the editor.
Begin by filling out Section I, which covers the purpose and effective date of change. Indicate if it’s a combination of entities, change of ownership, or merger/consolidation.
In Section II, provide detailed information about each entity involved. Enter names, locations, policy numbers, and FEIN numbers as required.
Proceed to Section III for ownership information. List all owners and their respective percentages of ownership for each entity.
Complete Section IV by adding the signature of the sole proprietor or executive officer along with their title and date signed.
Review all sections to ensure completeness before printing the form for submission. Remember that you cannot save changes directly on this PDF.

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When should an ERM-14 be completed?

Anytime an employer has a change in ownership the ICRB must be notified within 90 days via a completed and signed ERM-14 or narrative on company letterhead.

What is an ERM-14 form?

Any business that finds itself in a transformative process will most likely be introduced to the ERM-14, a form required by many state workers compensation bureaus to report changes in a businesss ownership, structure or status.

How do I submit an ERM-14 form?

The ERM-14 Form may be submitted via online application or PDF for reporting changes in ownership, mergers, consolidations, or a combination of entities. Submit Your Experience Rating Ownership Request Onlineincluding electronic signature!

Who completes an ERM-14 form?

The ERM-14 is a confidential form completed by the insured and submitted to the NCCI for the purpose of assisting the various workers compensation bureaus to verify coverage and determine combinability of entities as it relates to premium calculation.

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