Insurance Form U 26 3

Or c form si 12 certificate of workers compensation self insurance the business calls the board s self insurance office at 518 402 0247 or gsi 105 2 certificate of participation in worker s compensation group self insurance.

Insurance form u 26 3. Form db 120 1 issued by your insurance carrier form db 155. For assistance in creating an online account please contact nysif s contact center at 888 875 5790. To use this form new york ny must be listed under item 3a on the information page of the workers compensation insurance policy. The state insurance fund provides its own version of this form the u 26 3.

Please note that the state insurance fund issues a different form the u 26 3 form as its version of the c 105 2 employers insured for workers compensation through a private insurance carrier filed with any entity requesting to be a certificate holder including a government agency issuing a permit license or contract. Disability insurance submit one from this list. This certifies that the insurance carrier indicated above in box 3 insures the business referenced above in box 1a for workers compensation under the new york state workers compensation law. The nys state insurance fund uses the u 26 3 form as its certificate of nys workers comp insurance.