Get Form C 10511

Filling out Form C 10511 is essential for insurance corporations to comply with the New York State Workers' Compensation Board regulations. This guide provides a clear, step-by-step approach to completing the form online, ensuring all necessary information is accurately captured.

Follow the steps to complete Form C 10511 successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in the form editor.
2. In the first section, enter the name of the insurance corporation. Provide accurate and complete information to ensure proper identification of the entity.
3. Next, indicate the state where your insurance corporation is organized. This is important for establishing regulatory jurisdiction.
4. Provide the principal place of business address for your insurance corporation. Ensure the address is correct to receive all necessary correspondence.
5. You will need to specify the state(s) where the corporation is authorized to do business. List all applicable states.
6. Fill in the details regarding the policyholder’s name and the coverage details. This is crucial for confirming that the policy meets the requirements of the New York Workers' Compensation Law.
7. Review the portion about the appointment of the Secretary as the attorney for service of process. This section ensures that the proper legal representation is established.
8. In the final section, confirm the validity and agreement to the coverage provided under the policy described in the form. Check the compliance with the Workers' Compensation Law.
9. Once all sections are accurately completed, save your changes. You may also download, print, or share the form as needed.

Complete your Form C 10511 online today to ensure compliance with the New York State Workers' Compensation Board.