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Click ‘Get Form’ to open the 2016 NY Insurer Annual Form PDF in the editor.
Begin by entering the 'Name of Self-Insured' and 'FEIN #' at the top of the form. Ensure accuracy as this information is crucial for identification.
Fill in the 'Carrier ID #' and provide details for the 'Primary Contact' section, including name, title, telephone number, email address, fax number, and mailing address.
Repeat the process for the 'Assessment Reporting & Billing Contact' section. Make sure to include all relevant contact details.
If applicable, add any additional contacts by filling out their respective sections with accurate information.
List any active subsidiaries involved in your self-insurance program along with their FEIN numbers.
Indicate whether claims are self-administered or handled by a TPA. If using a TPA, complete the corresponding section with their details.

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Versions	Form popularity	Fillable & printable
2016	4.9 Satisfied (300 Votes)
2015	4.4 Satisfied (52 Votes)

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