Get Ny Self-insurer's Annual Update Form 2016-2025

This guide provides a comprehensive overview of how to complete the NY Self-Insurer's Annual Update Form online. Follow the instructions carefully to ensure accurate submission of your information.

Follow the steps to successfully complete the form online:

1. Press the ‘Get Form’ button to access the NY Self-Insurer's Annual Update Form and open it in your preferred editing tool.
2. Begin by entering the name of the self-insured organization along with the Federal Employer Identification Number (FEIN) and Carrier ID number in the appropriate fields.
3. In the Primary Contact section, provide the name, title, telephone number, email address, fax number, and mailing address of the primary contact person responsible for the self-insured entity.
4. Fill out the Assessment Reporting & Billing Contact section with the name, title, telephone number, email, fax, and mailing address of the assessment reporting and billing contact person.
5. If there are additional contacts, fill in the respective fields for any additional contact persons, including their name, title, telephone, email, fax, and mailing address.
6. List all active subsidiaries under your self-insurance program by providing their names and corresponding FEIN numbers in the designated areas.
7. Indicate whether claims are self-administered by the self-insured employer or administered by a Third Party Administrator (TPA). If administered by a TPA, provide the TPA information and relevant contact details.
8. If claims are not managed by a single TPA throughout the entire period of self-insurance, record details of additional claims administrators, including their contact information and the dates of accidents they managed.
9. Lastly, review all filled sections to ensure accuracy, then save your changes, download, print, or share the completed form as necessary.

Complete your NY Self-Insurer's Annual Update Form online today!