Get Ny Si-21 2017-2025

Filling out the NY SI-21 form, also known as the Certificate of Excess Insurance Contract for Self-Insurer, is an essential step for self-insured employers. This guide will provide comprehensive, step-by-step instructions to assist you in completing the form efficiently and accurately.

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

1. Press the ‘Get Form’ button to obtain the document and open it in an online editor.
2. Begin by entering the name of the Excess Insurance Carrier in the designated field at the top of the form.
3. Next, provide the address of the Excess Insurance Carrier, including city, state, and zip code.
4. Indicate the name of the Self-Insurer and their Workers' Compensation number in the specified fields.
5. Fill in the address of the Self-Insurer in the section provided.
6. Enter the contract number for the Excess Insurance Contract in the assigned field.
7. Specify the contract effective date and note that it remains in force until canceled.
8. Document the Company's limits of liability for each occurrence in the respective area.
9. Provide the Self-Insurer's retention amount for each occurrence where indicated.
10. Complete the date section at the bottom of the form, including the day, month, and year.
11. Ensure the authorized representative of the Excess Insurance Company signs the form in the designated area.
12. Print the name of the authorized representative and provide their phone number, including area code.
13. Attach evidence of authority as required.
14. Once all sections are completed, save your changes, and choose the options to download, print, or share the form as needed.

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