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How to use or fill out Justia :: Certificate Of Excess Insurance - State Forms with DocHub
- Click ‘Get Form’ to open it in the editor.
- Begin by entering the name of the Excess Insurance Carrier in the designated field at the top of the form.
- Next, fill in the address, city, state, and zip code of the insurance carrier to ensure accurate identification.
- In the section certifying the Workers’ Compensation Excess Insurance Contract, confirm that it is currently in force. This is crucial for compliance.
- Provide details about the Self-Insurer, including their name and address. Make sure to include their Worker’s Compensation number for reference.
- Fill in the contract number and specify its effective date. This information is vital for tracking purposes.
- Indicate the Company's Limits of Liability and Self-Insurer's Retention amounts as required by your policy.
- 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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