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Al ownership statements will be used only in establishing premiums for your insurance coverage s. Your workers compensation policy requires that you report ownership changes, and other changes as detailed below, to your insurance carrier in writing within 90 days of the change. If you have questions, contact your agent, insurance carrier, or the Rating Board. Once completed, this form must be submitted to the Underwriting Department of the Rating Board by you, your insurance carrier(s), or you.

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