Rson: Telephone #: E-Mail Address: Fax #: Mailing Address: City: State: Zip: Assessment Reporting & Billing Contact Name of Contact Person at Self-Insured: Title of Contact Person: Telephone #: E-Mail Address: Fax #: Mailing Address: City: State: Zip: Additional Contact (if applicable) Name of Contact Person at Self-Insured: Title of Contact Person: Telephone #: E-Mail Address: Fax #: Mailing Address: City: State: Zip: Additional Contact (if applicable) Name of Contact Perso.
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How to fill out the NY Self-Insurer's Annual Update Form online
The NY Self-Insurer's Annual Update Form is a crucial document for organizations that self-insure in New York. This guide provides clear and concise instructions on filling out this form online, ensuring you meet all requirements efficiently and accurately.
Follow the steps to complete your update form online:
- Locate and press the ‘Get Form’ button to access the NY Self-Insurer's Annual Update Form, opening it in your preferred online editor.
- Begin by entering the name of the self-insured organization and the Federal Employer Identification Number (FEIN) in the provided fields.
- Fill out the NYS UI Employer Registration Number and Carrier ID # B, ensuring you provide accurate information.
- In the primary contact section, include the name, title, telephone number, email address, fax number, and mailing address of the person designated to handle communications.
- Repeat the process for the Assessment Reporting & Billing Contact, filling in the required fields with accurate details.
- If applicable, complete any additional contact information by repeating the previous steps, providing the contact's name, title, and communication details.
- In the subsidiaries section, list the names and FEINs of all subsidiaries involved in the self-insurance program. Attach a separate list if there are more than can be accommodated in the form.
- Provide the TPA – Claims Administrator Information by including the name of the claims administrator, contact person, and their relevant communication details.
- Indicate whether the TPA handles all cases for the entire self-insurance period by selecting 'Yes' or 'No'. If 'No', detail any breakdown of claims administrators along with the dates associated with each.
- Once you have completed all sections, review the form for accuracy, then save your changes. You can opt to download, print, or share your completed form as needed.
Start completing your NY Self-Insurer's Annual Update Form online today!
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