Get Ny Si-21 2015-2026

The NY SI-21 form is essential for documenting a Workers’ Compensation Excess Insurance Contract for self-insurers in New York. This guide will provide you with an easy-to-follow process for filling out the form accurately and efficiently online.

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

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the Excess Insurance Carrier in the designated field. This identifies the provider responsible for the excess insurance coverage.
3. Next, provide the address of the Excess Insurance Carrier, including the street address, city, state, and zip code, ensuring all information is correct.
4. In the section that certifies the issuance of the Workers’ Compensation Excess Insurance Contract, confirm that it is currently in force and understand that the Carrier is required to give a written notice to the Workers' Compensation Board not less than thirty days prior to any cancellation or changes.
5. Fill in the name of the Self-Insurer, ensuring to include the legal name as recognized for self-insurance purposes.
6. Enter the Self-Insurer's address, making sure to include valid components such as the street address, city, state, and zip code.
7. Provide the Contract Number, which is essential for identifying the specific insurance contract associated with this filing.
8. Indicate the Contract Effective Date and ensure it accurately shows the start date of the coverage until it is canceled.
9. Specify the Company's Limits of Liability, making sure to adhere to statutory requirements for each occurrence.
10. Complete the Self-Insurer's Retention field by entering the specific amount for each occurrence that the self-insurer is responsible for retaining.
11. Include the date of signing in the specified format, ensuring that the day, month, and year are entered correctly.
12. Provide the name of the Excess Insurance Company and ensure it is printed alongside the authorized representative's information.
13. Enter the name of the Authorized Representative, verifying that they have the authority to sign off on this document. Attach evidence of this authority if required.
14. Lastly, enter the phone number of the authorized representative, including the area code, ensuring it is a reachable number for any inquiries.
15. After completing all fields, review your entries for accuracy. Once satisfied, proceed to save changes, download, print, or share the completed form as needed.

Start completing your NY SI-21 form online today for efficient processing.