Get Ny Si-21 2019-2025

The NY SI-21 form is essential for reporting excess workers' compensation insurance coverage in New York. This guide provides step-by-step instructions on how to accurately complete the form online, ensuring that all necessary information is submitted seamlessly.

Follow the steps to complete the NY SI-21 form online.

1. Click ‘Get Form’ button to access the NY SI-21 document and open it in your preferred digital editor.
2. Enter the name of the excess insurance carrier in the designated field at the top of the form.
3. Fill in the address of the insurance carrier, including the city, state, and ZIP code.
4. Provide the name of the self-insurer in the specified area. This should be the legal name of the entity seeking to self-insure.
5. Complete the address fields for the self-insurer, ensuring to include all relevant details.
6. Enter the policy number assigned to the excess insurance policy in the corresponding field.
7. Record the policy effective date, indicating when the insurance coverage began.
8. Specify the policy expiration date to clarify the duration of the coverage.
9. Document the company's limits of liability, clearly defining the amount per occurrence.
10. State the self-insurer's retention amount, indicating the financial responsibility retained by the self-insurer.
11. Complete the date field, ensuring to specify the day and month when the form is completed.
12. The authorized official should print their name, sign the form, and indicate their title and contact information.
13. Once all fields are completed, save your changes. You can then download, print, or share the completed form as needed.

Ensure your documentation is complete by filling out the NY SI-21 form online today.