Si 21 form 2026

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4.8 out of 5

69 votes

The document is a Certificate of Excess Insurance Contract for a self-insurer, certifying that a Workers' Compensation Excess Insurance Policy has been issued. It outlines the responsibilities of the insurance carrier, including notification requirements for policy changes or cancellations, and confirms that the policy meets New York State regulations. The document includes spaces for details such as the self-insurer's name, policy number, effective dates, limits of liability, and retention amount.

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Click ‘Get Form’ to open the si 21 form in the editor.
Begin by entering the name of the Excess Insurance Carrier and their address, including city, state, and zip code.
Fill in the details regarding the Self-Insurer, including their name and address.
Input the Policy Number, effective date, and expiration date of the insurance policy.
Specify the Company's Limits of Liability for each occurrence and enter the Self-Insurer's Retention amount.
Date the form appropriately and ensure that an authorized official signs it. Include their printed name, title, phone number, and email.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (69 Votes)
2017	4.4 Satisfied (43 Votes)
2015	4.3 Satisfied (138 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is an SR21?

the SR-21 is filed to protect such named insured as owner of the insured vehicle, against having his vehicle registration sus- pended. The same purpose applies to the preservation of the operators license. If there is any reliance it is only on the part of the State.

Do you have to turn in an accident report to the DMV SC?

You must file a written report with the Department of Motor Vehicles (DMV) showing proof of liability insurance when: The accident involves personal injury or death. There is more than $1,000 in property damage.

What happens if I dont fill out SR 1?

However, many California accident victims dont realize they must still file an SR-1 with the DMV. Failing to do so, even after police documentation, can lead to a suspended license.

What is the fax number for the New York State Workers Compensation Board?

Email to the Boards centralized email address, wcbclaimsfiling@wcb.ny.gov; Mail to the Boards centralized mailing address, P.O. Box 5205, Binghamton, NY 13902-5205; or. Fax to the Boards centralized fax number, (877) 533-0337.