<p> COMPANY COMMON OWNERSHIP MERGER/SEPARATION DECLARATION</p><p>Please mark and provide the requested information on the following pages if your Company is:</p><p>____ a Common Ownership Company, ____ becoming a Common Ownership Company, ______Effective Date ____ no longer a Common Ownership Company. ______Effective Date</p><p>____ 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.</p><p>______</p><p>______</p><p>______</p><p>______</p><p>____ 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.</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Please explain the changes that took place that caused these Companies to merge or separate:</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Signature (of legal binding representative of Company) ______</p><p>Title:______</p><p>Date:______</p><p>If this information changes, be advised that PreferredOne Community Health Plan (PCHP) reserves the right to re- underwrite the rates for this group.</p><p>Company Common Ownership Declaration Form 1 COMMONLY CONTROLLED GROUP WORKSHEET</p><p>Where is the office of your Company’s Chief Executive Officer (CEO)? ______</p><p>Company A: ______Number of employees working a Location(s): ______minimum of 20 hours:______</p><p>Owners/Partnerships: ______% ______% ______%</p><p>Company B: ______Number of employees working a Location(s): ______minimum of 20 hours:______</p><p>Owners/Partnerships: ______% ______% ______%</p><p>Company C: ______Number of employees working a Location(s): ______minimum of 20 hours:______</p><p>Owners/Partnerships: ______% ______% ______%</p><p>Please list additional Companies or pertinent information: ______</p><p>Name of umbrella Company:______</p><p>Do you share employees between Companies? ____Yes ____No</p><p>Comments: ______</p><p>______Signature (CEO/Owner/Authorized Company Representative) Date</p><p>In addition to the information that you have provided above please include the following documents:</p><p> Quarterly Wage & Tax Report for each Company.  A copy of your Organizational Chart (if available).</p><p>Company Common Ownership Declaration Form 2 COMMONLY CONTROLLED GROUP WORKSHEET</p><p>Where is the office of your Company’s Chief Executive Officer (CEO)? ______</p><p>Company D: ______Number of employees working a Location(s): ______minimum of 20 hours:______</p><p>Owners/Partnerships: ______% ______% ______%</p><p>Company E: ______Number of employees working a Location(s): ______minimum of 20 hours:______</p><p>Owners/Partnerships: ______% ______% ______%</p><p>Company F: ______Number of employees working a Location(s): ______minimum of 20 hours:______</p><p>Owners/Partnerships: ______% ______% ______%</p><p>Please list additional Companies or pertinent information: ______</p><p>Name of umbrella Company:______</p><p>Do you share employees between Companies? ____Yes ____No</p><p>Comments: ______</p><p>______Signature (CEO/Owner/Authorized Company Representative) Date</p><p>In addition to the information that you have provided above please include the following documents:</p><p> Quarterly Wage & Tax Report for each Company.  A copy of your Organizational Chart (if available). </p><p>Company Common Ownership Declaration Form 3</p>