Application For Self-Insurance (Workers Compensation Law)) {SI-1} | Pdf Fpdf Docx | New York

 New York   Workers Compensation 
Application For Self-Insurance (Workers Compensation Law)) {SI-1} | Pdf Fpdf Docx | New York

Last updated: 10/13/2025

Application For Self-Insurance (Workers Compensation Law)) {SI-1}

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Description

SI-1 - APPLICATION FOR SELF-INSURANCE WORKERS' COMPENSATION LAW. This form is issued by the New York State Workers’ Compensation Board for employers seeking authorization to self-insure under Section 50, subdivision 3 of the Workers’ Compensation Law. The form collects detailed company, financial, and employment information to determine eligibility and financial stability. Applicants must attach audited financial statements for the past three years, a certified foundation document, a company safety program, a five-year loss history, and a list of New York workplaces with employee counts. Submission of the application does not guarantee approval—coverage must remain active until a Notice of Qualification is issued. www.FormsWorkflow.com

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