Please complete, sign and submit the Common Ownership Certification. Renewing Groups- complete and return even if you do not have multiple companies. Please list all companies that are eligible to be included as part of a consolidated federal tax return (even if they don’t file a

File common owner changes and corrections by completing and mailing Form 05-177, Common Owner Information Report with a letter explaining the reason for the change or correction. Be sure your letter includes the following: Reporting entity Texas taxpayer number. Reporting entity taxpayer name. Common owner(s) identification information.

Please have this form completed and signed by an Authorized Representative of the Company. The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) states that all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer.

The common owner is the entity or individual that owns more than 50 percent (directly or indirectly) of each affiliate of the combined group. Note: The reporting entity is not necessarily the common owner.

This form should be completed by any group applying for coverage that has affiliated companies, subsidiaries or enough common ownership to apply for coverage under one entity. This form should be completed and signed by the group’s accountant, attorney or officer of the company and returned along with the group contract application.

Common Ownership Certification Please complete, sign and submit the Common Ownership Certification. This form must be filled out and returned even if you do not have multiple companies .

applying for one policy of group coverage due to common ownership. This form should be signed by the group’s accountant, officer of the company, legal counsel, or authorized representative.

Please complete, sign and submit the Common Ownership Certification. This form must be filled out and returned even if you do not have multiple companies. List all companies that qualify as one employer under Section 414 of the Internal Revenue Code of 1986.

Is your company a subsidiary of another company, an affiliate of another company, or under common control with another company? Does your company file state or federal taxes with another company(ies) on a combined or consolidated basis?

Common ownership groups must meet the definition of a small employer when combined Business entities that are affiliated and eligible to file a combined tax return for purposes of state taxation will