CONFIDENTIAL REQUEST FOR INFORMATION
The following confidential ownership statements may be used only in establishing premiums for your insurance coverages. It is extremely important that all questions be answered completely. 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 company, or the appropriate rating organization. Submit the completed form to the rating organization.
The NCCI address is:
National Council on Compensation Insurance
901 Peninsula Corporate Circle
Boca Raton, FL 33487
Phone: 800-NCCI 1-2-3