SELF INSURANCE

RSA 281-A:5-a provides for any private employer, or any homogeneous group of employers who qualify, to self-insure their workers? compensation.

New Hampshire regulation requires that the full sum of the self-insured retained risk be guaranteed; various types of guarantees are permitted, with the most common being a surety bond. Additionally, self-insurers must purchase excess insurance coverage which attaches at a point that leaves no gap between the sum of the guaranteed retained risk and the excess coverage. Also, please bear in mind that self-insured groups must be "Homogeneous" as defined in New Hampshire Administrative Rules Chapter LAB 404.01 Workers' Compensation Self-Insurance.

Self Insurance Forms

• Self-Insurance Application
  


• Self-Insurance Questionnaire
  


• Self-Insurance Surety Bond
  


• Certificate of Insurance
  


• Endorsement
  


• Annual Financial Statement
  


• General Purpose Rider
  


• Guarantee Proposal
  


• Outstanding Liabilities
  


• Securities Deposit Agreement
  


• Securities Deposit Agreement Past Liability
  

Third Party Administrator Forms

• Securities Deposit Agreement for Third Party Administrator
  


• Application for Certificate of Authority
  


• Notice of Contract Between Third Party Administrator and Self-Insurer
  


• Third Party Administration Bond
  


• Biographical Affidavit