Certification Of Excess Insurance Contract For Self Insurer (SI-21}

SI-21 - CERTIFICATION OF EXCESS INSURANCE CONTRACT FOR SELF-INSURER. This form is issued by the New York State Workers’ Compensation Board and must be completed by an authorized excess insurance carrier for employers approved as self-insurers under the Workers’ Compensation Law. The form certifies that a valid Workers’ Compensation Excess Insurance Policy is in effect and outlines the carrier’s limits of liability and the self-insurer’s retention per occurrence. It also requires confirmation that the carrier is authorized by the Superintendent of Financial Services to issue excess policies in New York and that the policy provides statutory coverage without a corridor deductible. Carriers must notify the Board at least 30 days before cancellation or changes to the policy. www.FormsWorkflow.com