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. Please enter your information, select print and choose Microsoft Print to PDF and submit the saved PDF. Please note, that if you do not Print to PDF, the entered data may not be transmitted resulting in a blank form being submitted. 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.
| Form Number / Version Date | Form Title | Who Files | Description of Form | When to File |
|---|---|---|---|---|
| SI-1 (08/23) | 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 |
| Form Number / Version Date | Form Title | Who Files | When Due | Where to Submit | Description of Form |
|---|---|---|---|---|---|
| SI-6 (12/22) | 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 |
| Form Number /Version Date | Form Title | Who Files | Where to File | When to File |
|---|---|---|---|---|
| SI-12 (7/23) | 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. | 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.