Form SI-12 is the New York Workers’ Compensation Board’s official certificate confirming that an employer has Board-approved self-insurance for workers’ compensation. You cannot fill it out yourself. To get one, email the WCB’s Self-Insurance Office at selfinsurance@wcb.ny.gov and ask them to prepare the certificate; they issue it, and you deliver it to the government agency that asked for proof of coverage.1Workers’ Compensation Board. Workers’ Compensation Self-Insurance Forms
How to Request the Certificate
Send your request to selfinsurance@wcb.ny.gov. Give the Self-Insurance Office enough to find your account and produce a useful certificate on the first try:
- Your company name and self-insurance identification number as they appear in WCB records.
- The name of the government agency requesting proof, plus the permit, license, or contract number the certificate relates to if you have one.
- A contact person and how you want the certificate returned, whether mailed to a specific address or emailed as a PDF.
The Board has not published a turnaround time. If a bid deadline or permit renewal window is driving your request, ask early and say so in the email. The WCB’s general customer service line is (877) 632-4996 if you need to follow up by phone.
Who the Form Is For
Only employers with Board-approved self-insurance use SI-12. Under Section 50 of the Workers’ Compensation Law, employers secure coverage in one of three ways: the State Insurance Fund, a private carrier authorized in New York, or by demonstrating to the WCB Chair the financial ability to pay claims directly and posting security in an amount the Chair sets.2New York State Senate. New York Workers’ Compensation Code 50 – Security for Payment of Compensation Employers approved under that third route are the ones who need SI-12, because there is no outside insurer to generate proof of coverage on their behalf.
If your coverage comes from the State Insurance Fund or a private carrier, SI-12 does not apply to you. Your insurer issues its own certificate of insurance, and that is what the requesting agency wants.
Giving the Certificate to the Agency
Once the SI-12 arrives, send it to whichever agency asked for proof. Some agencies accept a copy; others want an original carrying the Board’s stamp or signature. Ask the requesting agency before you submit so you do not have to go back to the WCB for a second issuance. Keep a copy in your own compliance files.
The certificate reflects your coverage status on the date the Board issues it. When an agency later needs updated proof, for a renewal or a new contract, you request a fresh SI-12 then. An old certificate will not satisfy a current requirement.
Keep Your Self-Insurance in Good Standing
An SI-12 only means something while your self-insurance is active. If the Board revokes your self-insured status for missed filings, the certificate becomes worthless. To stay in good standing, self-insured employers must submit the following to the WCB each year:3New York Workers’ Compensation Board. Individual Self-Insurance – Workers’ Compensation
- Certified, independently audited financial statements within 90 days after the fiscal year ends.
- Self-Insurers Report of Payroll (Form SI-6) by April 1.
- An actuarial report prepared under Board guidance, also by April 1.
- Certificate of Excess Insurance Contract (Form SI-21), filed before the current excess policy expires.
An employer who falls out of workers’ compensation coverage faces penalties of up to $2,000 for every 10-day period without coverage, and by the time the first penalty notice goes out the total may already exceed $12,000.4New York State Workers’ Compensation Board. Violations of Workers’ Compensation Law – Liability and Penalties Staying current on the annual filings is what keeps your SI-12 certificate valid when you need it.