Company Common Ownership Merger/Separation Declaration

COMPANY COMMON OWNERSHIP MERGER/SEPARATION DECLARATION

Please mark and provide the requested information on the following pages if your Company is:

____ a Common Ownership Company, ____ becoming a Common Ownership Company, ______Effective Date ____ no longer a Common Ownership Company. ______Effective Date

____ According to section 414 of the Internal Revenue Code, the following Companies are considered to be a single employer and should be covered together under one health insurance plan.

______

____ According to section 414 of the Internal Revenue Code, the following Companies are not considered to be a single employer and should not be covered together under one health insurance plan.

______

Please explain the changes that took place that caused these Companies to merge or separate:

______

Signature (of legal binding representative of Company) ______

Title:______

Date:______

If this information changes, be advised that PreferredOne Community Health Plan (PCHP) reserves the right to re- underwrite the rates for this group.

Company Common Ownership Declaration Form 1 COMMONLY CONTROLLED GROUP WORKSHEET

Where is the office of your Company’s Chief Executive Officer (CEO)? ______

Company A: ______Number of employees working a Location(s): ______minimum of 20 hours:______

Owners/Partnerships: ______% ______% ______%

Company B: ______Number of employees working a Location(s): ______minimum of 20 hours:______

Company C: ______Number of employees working a Location(s): ______minimum of 20 hours:______

Please list additional Companies or pertinent information: ______

Name of umbrella Company:______

Do you share employees between Companies? ____Yes ____No

Comments: ______

______Signature (CEO/Owner/Authorized Company Representative) Date

In addition to the information that you have provided above please include the following documents:

 Quarterly Wage & Tax Report for each Company.  A copy of your Organizational Chart (if available).

Company Common Ownership Declaration Form 2 COMMONLY CONTROLLED GROUP WORKSHEET

Where is the office of your Company’s Chief Executive Officer (CEO)? ______

Company D: ______Number of employees working a Location(s): ______minimum of 20 hours:______

Company E: ______Number of employees working a Location(s): ______minimum of 20 hours:______

Company F: ______Number of employees working a Location(s): ______minimum of 20 hours:______

Please list additional Companies or pertinent information: ______

Name of umbrella Company:______

Do you share employees between Companies? ____Yes ____No

Comments: ______

______Signature (CEO/Owner/Authorized Company Representative) Date

In addition to the information that you have provided above please include the following documents:

 Quarterly Wage & Tax Report for each Company.  A copy of your Organizational Chart (if available).

Company Common Ownership Declaration Form 3