The ownership information collected in this web application may be used in establishing premiums for your Workers Compensation and Employers Liability insurance coverages. Your workers compensation policy requires that you report ownership changes and other changes as detailed within, to your insurance carrier in writing within 90 days of the change. If any of the entities are interstate rated (doing business in multiple states), completion of an NCCI ERM-14 form may be required. Please contact our Information Center for additional information at 919-582-1056 or via email at firstname.lastname@example.org.
You hereby certify that you are either 1) the employer subject to this ownership form, or 2) the current carrier of record or producer of record for the employer organization (“Employer”). You agree to defend, indemnify, and hold NCRB and its directors, employees, and affiliates harmless from any and all claims, suits, actions, losses, damages, costs , and expenses (including reasonable attorneys’ fees) arising from or relating to your breach of this Certification and Agreement, including without limitation your failure to meet the certification requirements above. You acknowledge that NCRB may electronically capture and store your agreement to these terms along with your identifying information, which will link your acceptance with your email address.