Fillable GUARANTEE PROPOSAL TYPE AMOUNT (State of New Hampshire)

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GUARANTEE PROPOSAL TYPE AMOUNT (State of New Hampshire)

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U.S.A. forms for State of New Hampshire

BROWSE STATE OF NEW HAMPSHIRE (NH) FORMS

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GUARANTEE PROPOSAL
TYPE
AMOUNT
Surety Bond $_________________________
Deposit of Cash _________________________
Deposit of Securities _________________________
Excess Insurance Per Loss _________________________
Aggregate Excess Insurance _________________________
Letter of Credit _________________________
Parent Company Support _________________________
TOTAL $ _________________________
Amount of risk retention……………………………………………………………………………………
Attaching point of excess insurance…………………………………………………………………………
Do you maintain a dispensary or other first aid facility in each establishment?……………………………
If so, describe the equipment, personnel and service available………………………………………………
……………………………………………………………………………………………………………….
If not, state what arrangements you have made to provide medical services to injured employees…………
……………………………………………………………………………………………………………….
Do you agree without any reservation, to notify this Department immediately of any change in financial
circumstances which might impair your ability to satisfy any and all liability which you may incur as a
self-insurer?…………………………………...
Do you agree with reservation, to comply fully with the said stature and any rule or regulation promulgated
thereunder, and to furnish the Department readily with needed information?………………………..............
WCSI-1(1/92)
Balance Sheet Data (Annual Report may be substituted in lieu thereof)
ASSETS LIABILITIES
Cash ……………….. Accounts payable ……………………..
Accounts Receivable ………………. Notes payable …………………….
Notes Receivable ………………. Realty encumbrances…………………….
Inventory ………………. Mortgages ……………………
Real Estate ………………. Bonds ……………………
Machinery ………………. Capitol stock ……………………
Furniture and fixtures ………………. Surplus ……………………
Patent rights, trade-
marks, copyrights ……………….
Goodwill ………………..
TOTAL ……………….. TOTAL …………………….
NEW HAMPSHIRE REALTY
Location Equity
…………………………………………………………. ………………….
…………………………………………………………. ………………….
…………………………………………………………. ………………….
(use additional sheets if necessary)
Classification
of operations
Code
No.
No. of
Employees
Last Year's
Payroll
Next Year's
Estimated Payroll
TOTAL
WCSI-1 (1/92)
I/We the undersigned state that I/We have examined the information contained herein and find it to be true.
Subscribed to this …………………………………day of ……………………………..
20 , under the penalty of perjury.
Signature Title
………………………………………………. ………………………………………..
………………………………………………. ………………………………………..
………………………………………………. ………………………………………..
WCSI-1 (1/92)
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GUARANTEE PROPOSAL TYPE AMOUNT (State of New Hampshire)

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Completed 21 July 2020

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