
Tain duplicate.) To: CHAIR, WORKERS’ COMPENSATION BOARD TAKE NOTICE that this political subdivision or fire district has elected to secure compensation to its employees pursuant to subdivision 3 of section 50 of the Workers’ Compensation Law and files this completed notice in accordance with subdivision 4-a of said section. 1. a. A certified copy of the Resolution adopted, re: Self-Insurance, is attached. b. Other: (explain)________________________________________________________________.
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How to fill out the NY SI-26 online
This guide provides comprehensive instructions for completing the NY SI-26 form online, ensuring users understand each component and requirement. Follow the steps outlined below to accurately fill out the form and secure compensation as a self-insurer.
Follow the steps to complete the NY SI-26 form online.
- Press the ‘Get Form’ button to access the document and launch it in the editor.
- Begin by attaching a certified copy of the resolution adopted regarding self-insurance. This is a necessary document that confirms the political subdivision or fire district's decision to secure compensation according to the Workers’ Compensation Law.
- Next, enter the date on which the election to secure compensation was made in the specified field.
- Indicate the effective date of the election in the appropriate area.
- Provide information about how employees were covered prior to the effective date. If they were covered by an insurance policy, include the name of the insurance carrier and the policy number.
- Choose whether you intend to deal directly with your employees regarding compensation matters, or if you will do so through a licensed self-insurer's representative. If you select the latter, be sure to include the name and address of the representative.
- Fill in the name and address of your political subdivision or fire district.
- Ensure the designated official signs the form and includes their title and telephone number.
- After completing the form, review all sections for accuracy. Save your changes and then download, print, or share the form as necessary.
Complete your NY SI-26 form online today to ensure proper and timely self-insurance compliance.
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