Form WCSI-1A "Workers' Compensation Self-insurance Application - Group" - New Hampshire

What Is Form WCSI-1A?

This is a legal form that was released by the New Hampshire Department of Labor - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the New Hampshire Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form WCSI-1A by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Labor.

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Download Form WCSI-1A "Workers' Compensation Self-insurance Application - Group" - New Hampshire

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Lab 400
THE STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO Box 2076
CONCORD, NH 03301
WORKERS' COMPENSATION SELF-INSURANCE APPLICATION- GROUP
The undersigned on behalf of a homogenous group of employers intends to pay direct the
benefits in manner, amounts, and when due as provided by the Workers' Compensation
Law, RSA 281-A, as amended, and all rules and regulations promulgated thereunder, and
submits, for the purpose of obtaining authorization, the following information:
Name of Employers’ Association or Group
Principal office in NH
Full names and Federal Employers Identification Numbers of Employers in Group:
How long in business in NH (years)
Give location of all employers in NH and their principal functions (Use additional sheets
if necessary
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WCSI-1A (2/2016) Application
Lab 400
THE STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO Box 2076
CONCORD, NH 03301
WORKERS' COMPENSATION SELF-INSURANCE APPLICATION- GROUP
The undersigned on behalf of a homogenous group of employers intends to pay direct the
benefits in manner, amounts, and when due as provided by the Workers' Compensation
Law, RSA 281-A, as amended, and all rules and regulations promulgated thereunder, and
submits, for the purpose of obtaining authorization, the following information:
Name of Employers’ Association or Group
Principal office in NH
Full names and Federal Employers Identification Numbers of Employers in Group:
How long in business in NH (years)
Give location of all employers in NH and their principal functions (Use additional sheets
if necessary
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WCSI-1A (2/2016) Application
Lab 400
Balance Sheet Data (Annual Report may be substituted in lieu thereof)
ASSETS
LIABILITIES
Cash
Accounts Payable
Accounts Receivable
Notes Payable
Realty Encumbrances
Mortgages
Inventory
Bonds
Real Estate
Capitol Stock
Machinery
Surplus
Furniture and Fixtures
Patent rights, Trademarks,
Copyrights
Goodwill
TOTAL
TOTAL
NEW HAMPSHIRE REALTY
LOCATION
EQUITY
(Use additional sheets if necessary)
Classification
Code
Number of
Last Year’s
Next Year’s
Of Operation
Number
Employees
Payroll
Estimated Payroll
TOTAL
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WCSI-1A (2/2016) Application
Lab 400
GUARANTEE PROPOSAL
TYPE
AMOUNT
Surety Bond
$
Deposit of Cash
$
Deposit of Securities
$
Excess Insurance Per Loss
$
Aggregate Excess Insurance
$
Letter of Credit
$
TOTAL
$
Amount of risk retention;
Attaching point of excess insurance;
Do you maintain a dispensary or other first aid facility in each establishment?
If so, describe the equipment, personnel and service available;
If not, state what arrangements you have made to provide medical services to injured
employees;
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WCSI-1A (2/2016) Application
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Do you agree without any reservation, to notify this department immediately of any
change in financial circumstances, which might impair your ability to satisfy any and all
liability, which you may incur as a self-insurer?
Do you agree without any reservation, to comply fully with the said statute and any rule
or regulation promulgated thereunder, and to furnish the department readily with needed
information?
I/We the undersigned state that I/We have examined the information contained
herein and find it to be true.
False Statements on this form may be punished under RSA chapter 641.
Signature
Date
Title
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WCSI-1A (2/2016) Application
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