New York > Workers Compensation
Stockholder Of Corporation Applying For License To Represent Self-Insurers OC-403.3 - New York
| Stockholder Of Corporation Applying For License To Represent Self-Insurers Form. This is a New York form and can be used in Workers Compensation . |
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STOCKHOLDER OF CORPORATION APPLYING FOR LICENSE TO REPRESENT SELF-INSURERS UNDER SECTION 50 3-b or 50 3-d OF THE WORKERS' COMPENSATION LAW If applicant corporation is a subsidiary, this form should be completed by chief executive officer of parent corporation. State of New York WORKERS' COMPENSATION BOARD If additional information is needed, call the Licensing Unit at (1-800)664-2379 or (518)402-1372. 1. Name of applicant corporation__________________________________________________________ 2. Name of stockholder_________________________________________________________________ Address___________________________________________________________________________ 3. Stockholder's Social Security No._________________ Federal Employer ID No. __________________ See Privacy Notification below. If you have neither number, explain: __________________________ __________________________________________________________________________________ __________________________________________________________________________________ 4. Specify percentage of stock owned______________________________________________________ 5. Have you (or if a corporation, the corporation or any of the officers thereof) ever been convicted of a crime? q Yes q No If Yes, state when and give details: _________________________________ __________________________________________________________________________________ Are there any criminal charges now pending against you (or if a corporation, against the corporation or any of the officers thereof)? q Yes q No If Yes, give details: _____________________________ __________________________________________________________________________________ __________________________________________________________________________________ 6. Do you own stock in any corporation which to your knowledge has been granted self-insurer's status under the New York State Workers' Compensation Law? q Yes q No If Yes, give details: ________ __________________________________________________________________________________ __________________________________________________________________________________ 7. Do you own stock in any corporation (other than applicant corporation) licensed or authorized to write workers' compensation insurance in New York State? q Yes q No If Yes, give details: _____ __________________________________________________________________________________ __________________________________________________________________________________ _______________________________________________ Signature of Stockholder of Corporation (or Chief Executive Officer of Parent Corporation*) * If application is signed by other than chief executive officer of parent corporation, attach a copy of corporate resolution delegating the authority to sign on behalf of the signing officer. PRIVACY NOTIFICATION The authority to request personal information from you, including identifying numbers such as Federal Social Security and Federal Employer Identification Numbers, and the authority to maintain such information, is found in Section 5 of the Tax Law. Disclosure of this information by you is mandatory. The principal purpose for which this information is collected is to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns or may have understated their tax liabilities and to generally identify persons affected by the taxes administered by the Commissioner of Taxation and Finance. The information will be used for tax administration purposes and for any other purpose authorized by the Tax Law or the Workers' Compensation Law. The information collected will be held by the Office of the Secretary, Workers' Compensation Board. All inquiries regarding such records should be addressed to the Privacy Compliance Officer, Office of the General Counsel, Workers' Compensation Board, 20 Park Street, Albany, New York 12207 (518) 486-9564. OC-403.3 (2-12) American LegalNet, Inc. www.FormsWorkFlow.com IF STOCKHOLDER IS AN INDIVIDUAL, USE THIS FORM OF VERIFICATION State of New York ) ss: County of ________________________) ________________________________________________, being duly sworn, deposes and says that I am the applicant; that I have duly read and signed the foregoing application; that all the matters contained herein are true, excepting as to such matters therein stated to be alleged on information and belief and those matters I believe to be true. In addition, I hereby authorize duly designated employees of the Workers' Compensation Board to make inquiry into and obtain disclosure of any information required to obtain verification of any statement made in this application. ____________________________________________ Signature of Stockholder Sworn to before me this ________day of ______________ 20____ __________________________________ Notary Public NOTARY'S STAMP IF STOCKHOLDER IS A CORPORATION USE THIS FORM OF VERIFICATION State of New York ) ss County of ________________________) _______________________________________, being duly sworn, deposes and says that (s)he is the _________________________________ (title) of ______________________________(parent corp.), Inc., which corporation owns ________% of the shares of _________________________________(subsidiary), Inc.; that (s)he has duly read the foregoing and that all matters contained therein are true, excepting as to such matters therein stated to be alleged on information and belief and as to those matters (s)he believes to be true. ______________________________________________ Signature of Qualifying Officer of Parent Corporation Sworn to before me this ______day of _____________ 20____ ______________________________ Notary Public NOTARY'S STAMP OC-403.3 Reverse (2-12) American LegalNet, Inc. www.FormsWorkFlow.com
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