Individual Changes in Name, Address, and Business Structure

Under NCGS 97-180(e), every self-insurer shall report promptly to the Commissioner changes in the names and addresses of the businesses it self-insures or intends to self-insure as well as changes in business structure including its divisions, subsidiaries, affiliates, and internal organization. Any changes shall be reported in writing to the Commissioner within 10 days of the effective date of change.

Employer Identification Notification Date (mm/dd/yyyy) Employer Code Employer Name

Employer or Subsidiary Name and Address Change New Employer / Subsidiary Name Previous Employer / Subsidiary Name Effective Date of Change (mm/dd/yyyy)

New Physical Address Street Address City State Zip Code Company Contact Contact’s Telephone Number

New Mailing Address Street Address / Post Office Box City State Zip Code Company Contact Contact’s Telephone Number

Third Party Administrator (TPA) Change New TPA Previous TPA Effective Date of Change (mm/dd/yyyy)

North Carolina Subsidiary Additions Name of Acquired Subsidiary Date of Acquisition (mm/dd/yyyy) Percentage Ownership Total Uninsured Loss Claims Requested Date to Self-Insure (mm/dd/yyyy)

North Carolina Subsidiary Deletions Name of Disposed Subsidiary Effective Termination Date (mm/dd/yyyy)

Mergers and Acquisitions Effective Date of Merger / Acquisition (mm/dd/yyyy) Name of Acquired Company Name of Surviving Company Surviving Company’s Fiscal Year End (mm/dd/yyyy)

Signature Signature of Authorized Company Officer Title of Authorized Company Officer Date (mm/dd/yyyy)