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New york si26 district

New york si26 district 2026

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158 votes

The document is a notice from a political subdivision or fire district in New York indicating their election to secure workers' compensation as a self-insurer, in accordance with the Workers’ Compensation Law. It includes details such as the effective date of the election, previous coverage information, and whether they will handle compensation matters directly or through a representative.

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Click ‘Get Form’ to open it in the editor.
Begin by attaching a certified copy of the resolution regarding self-insurance. Use the designated field to upload your document.
Enter the date when the election to secure compensation was made in the provided field.
Specify the effective date of this election in the corresponding section.
If applicable, provide details about previous coverage, including the name of the insurance carrier and policy number.
Indicate whether you will handle compensation matters directly or through a licensed representative. If you choose a representative, fill in their name and address.
Complete the form by entering your political subdivision or fire district's name and address, followed by signing and dating it.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (123 Votes)
2005	4.4 Satisfied (158 Votes)

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