New york si26 district 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by attaching a certified copy of the resolution regarding self-insurance. Use the designated field to upload your document.
  3. Enter the date when the election to secure compensation was made in the provided field.
  4. Specify the effective date of this election in the corresponding section.
  5. If applicable, provide details about previous coverage, including the name of the insurance carrier and policy number.
  6. Indicate whether you will handle compensation matters directly or through a licensed representative. If you choose a representative, fill in their name and address.
  7. 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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