The forms below are relevant to self-insureds.
Click here to view documents for self-insureds.

Annual Report of Self-Insurer's Payroll by City, Town or County School Boards (Form 26B)

 This report is for Individual Public-Board of Education or School Board Self-Insurers to report their payroll to the Commission, broken down by NCCI payroll classifications for tax assessment purposes.

The Individual Public-Municipal Self-Insurer will complete the form, have it notarized and return the original copy to the Commission on or before March 15th

Annual Payroll Report of City, Town or County Operating as a Self-Insurer (Form 26C)

 This report is for Individual Public-Municipal Self-Insurers to report their payroll to the Commission, broken down by NCCI payroll classifications for tax assessment purposes.

The Individual Public-Municipal Self-Insurer will complete the form, have it notarized and return the original copy to the Commission on or before March 15th.

Letter of Credit

 The Irrevocable Letter of Credit form is for use when a Self-Insurer elects to use Letter of Credit to satisfy their security requirement.

The form language must not be altered and all parts of the form must be completed in its entirety. Those parts include; The Irrevocable Letter of Credit face (S121-B), The Information Page (S121-C) and the Memorandum of Understanding (S121-D).

The Notice of Non-Renewal of the Letter of Credit (S121-E) is made a part of this form for future use.