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1. Enter Federal Number, Business Name and Address Tennessee ID Number M. No. County Alt Zip Federal Number ___ ___ - ___ ___ ___ ___ ___ ___ ___ Employer Name ________________________________________ Liab. Org. First Employment Date Liable ________________________________________

Trade Name ________________________________________

Comp Year NAICS M-NAICS Verified ________________________________________

Mailing Address ________________________________________

Previous No. Rate ________________________________________


PHYSICAL BUSINESS ADDRESS in Tennessee if different from above:



______________________________________________________ Phone:____________________ Fax:___________________

Business Website:_______________________________________ Email Address: ______________________________________

2. Have you previously had an account with this department? YES NO If YES, Account Number _______________________

3. Is your organization a Professional Employer Organization (PEO)? If YES, Tennessee license number ________________

YES NO Is your organization a client of a Professional Employer Organization (PEO)? YES NO If YES, STOP. STOP

–  –  –

(B) Account Number of predecessor employer ______________________ (C) Date of acquisition ___________________

(D) Did you acquire all of your predecessor’s business in Tennessee? YES NO If No, what percentage did you acquire? _________

–  –  –

(F) Tennessee Employment Security Law provides for the mandatory transfer of an employer’s benefit and premium experience whenever there is any common ownership, management or control between the predecessor and successor employers.

Did any owner or manager of this company have an ownership interest in or participate in the management or control of the business acquired? YES NO If “YES,” please explain: _____________________________________________________________________________________

Per TCA 50-7-403(b)(2)(C)(ii) “Common ownership, management or control” includes any individual who has at least a 10% ownership interest in or who participates in the management or control of - the predecessor’s trade or business and has a relative with a 10% ownership interest in - or who participates in the management or control of - the successor’s trade or business.

Does anyone who had a 10% or more ownership interest in the previous company - or who participated in its management or control have a relative with a 10% or more interest in this company or who participates in its management or control?

YES NO If “YES,” please explain: ____________________________________________________________________

If you are not subject to a mandatory transfer of experience but wish to succeed to the experience of the predecessor employer, Form LB-0483, Application for Transfer of Experience Rating Record, must be submitted by no later than the end of the quarter following the quarter in which the acquisition occurred.

12. Enter below the amount of total payroll for each quarter in which you have had or expect to have employment.



(A) Describe the major business activity of the account to be covered, listing any products manufactured or sold, or service provided.

Be as descriptive as possible. ________________________________________________________________________________



(B) In what Tennessee County is your company located? ________________________________________________________

(If account covers sales reps or other personnel working from home, list county or city of residence.) (C) Is the primary purpose of the employee(s) covered by this application to support other locations of your company? YES NO If YES, then check the category that best applies. Add comments as necessary.

HEADQUARTERS (e.g., corporate or regional management offices) _________________________________________________

ADMINISTRATIVE (e.g., bookkeeping, accounting, payroll, HR, PR) ________________________________________________

WAREHOUSING (e.g., storage, distribution, equipment yard) _____________________________________________________

SALESMAN (indicate product) ____________________________________________________________________________

INFORMATION TECHNOLOGY (e.g., software publication, programming, systems design, data processing) _________________

OTHER (e.g., repair shop, security office, maintenance, employee recreation facility) ____________________________________

(D) Below are some industries that often need additional clarification. This section may not apply to every employer. If you see your industry, please answer the corresponding question(s).

Construction: What type of construction? __________________________________ Mostly residential or non-residential?

Property Mgmt.: Does this business manage property for others or for itself? Mostly residential or non-residential?

Trucking: Is the main trucking activity local or long distance? Mostly truckload or less than truckload?

Empl. Agency: Is this a Temporary Staffing Service or an Employment Placement Agency?

Health Care: Is this a Doctor’s Office, Multi-Disciplinary Clinic, Freestanding Urgent Care Center or Other?

Please specify. ______________________________________________________________________________________________

Info Tech (IT): Which category best fits your business? Software Publication, Programming, Systems Design, Data Processing Restaurant: Is the restaurant Full Service, Fast Food, Cafeteria/Buffet, Snack Bar, Other? Please specify. _____________________

Consulting: What is the primary type of consulting? Administrative, Human Resources, Marketing, Process/Logistics, Environmental, or Other - Please specify. _____________________________________________________________________

Home Health: Does the care involve skilled nursing? YES NO Retail: What is the primary product? ___________________________________________________________________________________

Wholesale: What is the primary product? ___________________________________________________________________________________

Mining: What is the primary product? ___________________________________________________________________________________

Convenience Store: Does the store sell gasoline? YES NO Manufacturing: What is the primary product? ___________________________________________________________________________________

–  –  –

Enclosed is a Report to Determine Status/Application for Employer Number. The Tennessee Employment Security Law and Regulations requires each employing unit in Tennessee to file this report with the Department of Labor and Workforce Development for the purpose of determining status. If you answer “Yes” to question 7(d) or any one of the questions in items 8, 9 or 10 on the status application, you are liable for unemployment insurance coverage with this department. Please complete and submit the enclosed form as soon as you have paid wages for services performed in Tennessee.

The requirements for liability are:


Items 8 A and B on the status application do not pertain to farm or household employees.

–  –  –


Item 10A. During some part of a day in each of twenty weeks of a calendar year did you employ or do you expect to employ ten or more persons? (The weeks need not be consecutive and both full and part-time workers are counted.)

–  –  –

Item 10B. Have you paid or do you expect to pay wages of $20,000 or more in any calendar quarter?

Leave the space under Item 1 for Federal Number blank if you have not yet been assigned a FEIN (Federal Employer Identification Number). You will receive a letter asking for this number after we establish your state account. Return the letter with your FEIN when you receive the number from the Internal Revenue Service.

If you are completing quarterly reports and/or the Application for Transfer of Experience Rating (LB-0483), please return them in the same envelope with this application. DO NOT write in the box titled State Account Number if you are submitting quarterly Premium (LB-0456) and Wage (LB-0851) Reports along with this application. Your new number will be recorded here when assigned.

Anyone who is paid for personal services by a corporation is considered to be an employee of the corporation even if that person is an officer and/or owns stock in the corporation.

NOTE: PLEASE BE SURE TO SIGN YOUR STATUS APPLICATION at the bottom and include the appropriate information.

Also, complete both pages of your Status Application form.

Failure to complete both pages of the application or to provide sufficient information upon which to correctly classify the industry code will result in the highest new employer rate being assigned.

–  –  –

New employers in Tennessee are initially subject to a “new employer” rate until their account has been subject to premiums and chargeable with benefits for thirty-six consecutive months ending on the computation date (December 31 of each year). They then become eligible, beginning on the next July 1, for a premium rate based on their individual reserve experience.

New employer rates are determined separately for each major industry group based on the combined reserve experience of each industry group as a whole. Presently, all industries, except construction, mining, and manufacturing have a new employer rate of 2.7%. The new employer rates for construction, mining, and manufacturing are listed below.

–  –  –

 NAICS Manufacturing Sector 31 includes food, beverage, and tobacco products, as well as textiles, leather, and apparel products.

 NAICS Manufacturing Sector 32 includes wood products, paper products, printing and related support activities, petroleum and coal products, chemical manufacturing, plastics and rubber products, and nonmetallic mineral products.

 NAICS Manufacturing Sector 33 includes metal products, machinery, computer and electronic products, electrical equipment, appliances, transportation equipment, and furniture manufacturing.

LB-0441 (Rev. 09-16) RDA 1559 Page 4

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