The SI-12 must be completed by the Board's Self-Insurance Office. Upon obtaining a permit, license, or contract from a government agency. Board-approved self-insurers must email the Board's Self-Insurance Office at [email protected] to obtain this form.

Statements of Information, Common Interest Development Statements and Publicly Traded Disclosure Statements can be filed online at bizfileOnline.sos.ca.gov. After the initial statement is filed, the following schedule can be used to determine the filing period when subsequent statements are due:

Page 3 of 3 Form SI-12 (Rev. 8/01/2006) We further agree as follows: A. To accept and be bound by the provisions of the Arkansas workers’ compensation laws. B. That, by application and reference, the terms and provisions of the Group Indemnity …

The SI-12 must be completed by the Board's Self-Insurance Office. Upon obtaining a permit, license, or contract from a government agency. Board-approved self-insured employers must obtain this form from the Board's Self-Insurance Office by emailing [email protected]

Self-insured employers can contact the Office of Self-Insurance at [email protected] for the Certificate of Self-Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law (Form DB-155).

Instructions for Form SI-12 — Certificate of Workers’ Compensation Self- Insurance 1. Employers that are authorized as fully self-insured for New York State workers’ compensation may obtain Form SI-12 by calling the Board’s Self-Insurance Office at 518-402-0247.

C) Form SI-12, Certificate of Workers’ Compensation Self-Insurance available from the New York State Workers’ Compensation Board’s Self-Insurance Office. D) Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance

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2022年8月23日 · Form DB-120.1 Certificate of Insurance Coverage is the most common insurance form submitted by organizations. A sample form is provided on page 4 of this document.

Before a Department of Health permit can be issued, you must prove compliance with NYS Workers’ Compensation AND Disability and Paid Family Leave Benefits Insurance requirements. The following forms must be submitted with each permit application: 1. Workers' Compensation (Submit one from this list): 2.