New Hampshire Code of Administrative Rules
Lab - Commissioner, Department of Labor
Chapter Lab 300 - WORKERS' COMPENSATION INSURANCE COVERAGE
Part Lab 304 - COVERAGE RESPONSIBILITY
Section Lab 304.05 - Self-Insurance, Homogenous Self-Insured Groups and Third Party Administrators

(a) Self-insured employers, homogenous self-insured groups and third party administrator shall provide access to all prescribed coverage and claims forms. Supplies of these forms shall not be provided by the department.

(b) Self-insured employers, homogenous self-insured groups and third party administrators shall furnish covered businesses with a sufficient number of forms "Notice of Compliance" WCP-1(4-2014), contained in appendix II.

(c) The self-insured employers, homogenous self-insured groups and third party administrator shall complete and file "Notice of Workers Compensation Insurance Coverage" form 6WC (4/2008), "Supplemental Notice of Coverage" form 6WC-S (3/2013), "Notice of Termination" form WC 100 (10/1991), "Notice of Reinstatement" form WC-100R (9/2015) as well as an "Exclusion of Executive Officers or Members" form 6WCex (7/2015), all contained in appendix II when applicable as prescribed by Lab 306 and Lab 307.

(d) The self-Insured employers, homogenous self-insured groups and third party administrators shall forward by certified mail a copy of the "Exclusion of Executive Officers or Members" form 6WCex (7/2015) contained in appendix II to each of the executive officers or members listed on the form.

(e) Self-insured employers, homogenous self-insured groups and third party administrator shall contact the department to be assigned a carrier identification number prior to underwriting coverage in New Hampshire.

(f) The self-insured employers, homogenous self-insured groups and third party administrators responsibilities delineated above shall pertain solely to workers' compensation insurance.