Self-Insurance Application Form - Department Of Labor Of State Of New Hampshire printable pdf download

STATE OF NEW HAMPSHIRE

DEPARTMENT OF LABOR

PO BOX 2076

CONCORD, NH 03302-2076

SELF-INSURANCE APPLICATION FORM

The undersigned employer 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 Employer..................................................................................................

State of Incorporation..............................................................................................

Principal office in NH...............................................................................................

Principal office outside NH......................................................................................

Names, titles and addresses of owners, officers or members conducting the

business..................................................................................................................

................................................................................................................................

How long in business in NH (years)........................................................................

If employer is a subsidiary, name of parent company.............................................

................................................................................................................................

Give location of all establishments in NH and their principal functions.

(Use additional sheets if necessary).......................................................................

................................................................................................................................

I/We the undersigned state that I/We have examined the information contained

herein and find it to be true.

Subscribed to this.............................. date of....................................19

under the penalties of perjury.

Signature

Title

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Self-Insurance Application Form - Department Of Labor Of State Of New Hampshire