Free F207-095-000 self-insured employer certificate of excess insurance - Washington

Department of Labor and Industries Self-Insurance Section PO Box 44891 Olympia WA 98504-4891 Non-USPS delivery: 7273 Linderson Way SW Tumwater WA 98501

SELF-INSURED EMPLOYER CERTIFICATE OF EXCESS INSURANCE

It is necessary to complete this form if your firm elects to reinsure its workers' compensation liability. Please have your insurance provider assist you in properly completing this form. This information is required in accordance with RCW 51.14.020(5) and WAC 296-15-121(7).
Official Use only Self-Insurer Excess Insurer Address of Excess Insurer UBI Account ID

Policy Number

New Policy Policy Renewal (old policy number, if changed): Change to Policy Cancellation of Policy (effective date of cancellation): Reinstatement of Policy
Policy period from

to

Type of Policy

SPECIFIC: AGGREGATE:
(stop loss)

Retention Retention

Maximum Liability of Excess Insurer Maximum Liability of Excess Insurer

This policy contains the following endorsements:

Yes

No

This policy is not intended to provide for the payment of any costs, benefits or compensation which the self-insured employer may be obligated to pay pursuant to the provisions of Title 51 RCW, in excess of 80% of any such liabilities, as required by RCW 51.14.020(5). It is further understood that this excess insurance company and its personnel do not participate in the administration of the responsibilities of the self-insured under Title 51 RCW.

Yes

No

Date

Excess Insurer

By

F207-095-000 self-insured employer cert. of excess insurance 9-01

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