Justia :: Certificate Of Excess Insurance - State Forms 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the Excess Insurance Carrier in the designated field at the top of the form.
3. Next, fill in the address, city, state, and zip code of the insurance carrier to ensure accurate identification.
4. In the section certifying the Workers’ Compensation Excess Insurance Contract, confirm that it is currently in force. This is crucial for compliance.
5. Provide details about the Self-Insurer, including their name and address. Make sure to include their Worker’s Compensation number for reference.
6. Fill in the contract number and specify its effective date. This information is vital for tracking purposes.
7. Indicate the Company's Limits of Liability and Self-Insurer's Retention amounts as required by your policy.
8. Finally, sign and date the form where indicated, ensuring that an authorized representative completes this step. Attach any necessary evidence of authority as instructed.

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