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Workers’ Compensation Self-Insurance Forms

Forms

Completing Forms

If you require assistance with completing these forms, please contact the Self-Insurance Office at selfinsurance@wcb.ny.gov.

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it. If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. If you still have trouble with the form, please email the Board's Forms Department.

Multi-page Forms
Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.


Self-Insurance Application Forms
Form Number / Version Date Form Title Who Files Description of Form When to File
SI-1 (07/10) Application for Self-Insurance Employers Filed by an applicant for self-insurance under the WCL When appropriate
SI-26 (11/16) Notice of Election by a Political Subdivision, Ambulance or Fire District (for Self-Insurance) Political subdivision, ambulance or fire district Notice to the Chair that a political subdivision, ambulance or fire district has elected to secure compensation as a self-insurer When appropriate
Self-Insurance Annual Report Forms and Guides
Form Number / Version Date Form Title Who Files When Due Where to Submit Description of Form
SI-6 (1/20) Self-Insurer's Report of Payroll for All Operations Qualified Active Self-Insurer April 1st Email completed form to the Workers’ Compensation Board at selfinsurance@wcb.ny.gov Self-Insurer's complete NYS payroll amounts by payroll classification codes-Due April 1st each year
Self Insurer’s Records Update Form (8/17) Self Insurer’s Records Update Form Qualified Active and Terminated Self-Insurer When Appropriate Email completed form to the Workers’ Compensation Board at selfinsurance@wcb.ny.gov Self-Insurer's company, contact, address, and TPA information update
SI-21 (9/19) Certificate of Excess Insurance Contract for Self-Insurer Excess Insurance Carrier of Qualified Active Self-Insurer   Email completed form to the Workers’ Compensation Board at selfinsurance@wcb.ny.gov Proof of Excess Insurance coverage executed by Self-Insurer's Excess carrier
Self-Insurance Certificates
Form Number /Version Date Form Title Who Files Where to File When to File
SI-12 (7/09) Affidavit Certifying That Compensation Has Been Secured Employers with Board-approved self-insurance for workers' compensation Filed with the government agency issuing a permit, license or contract. The SI-12 must be completed by the Board's Self-Insurance Office and approved by the Board's Secretary. Upon obtaining a permit, license or contract from a government agency. Board-approved self-insurers must email the Board's Self-Insurance Office at selfinsurance@wcb.ny.gov to obtain this form.
SI-105.2P (2/13) Certificate of Participation in Workers' Compensation County Self-Insurance Plan Employers participating in county self-insurance plans for workers' compensation Filed with the government agency issuing a permit, license or contract. The SI-105.2P must be completed by the county self-insurance administrator. Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their county self-insurance administrator. For further information contact the Board's Self-Insurance Office at selfinsurance@wcb.ny.gov
SIG-105.2 (1/12) Certificate of Participation in Workers' Compensation Group Board-approved self-insurance Employers participating in group self-insurance for workers' compensation Filed with the government agency issuing a permit, license or contract. The SIG-105.2 must be completed by the group self-insurance administrator. Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their group self-insurance administrator. For further information contact the Board's Self-Insurance Office at selfinsurance@wcb.ny.gov.

Common Workers' Compensation Forms

Forms for Insurers, Self-Insured Employers and Third-Party Administrators


If the form you are looking for is not listed above, or in the list of Common Board Forms, please email the Board's Forms Department.