Certificate Request – Keevily Safety Groups

500 Mamaroneck Ave. Harrison, NY 10528

Monday to Friday 8:30 am to 5:00 pm

1 (800) 523-5516

For 90 years, New York State Fund Workers Comp Safety Groups have delivered value and savings through upfront premium discounts and backend group dividends.

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Insured Information
Name of Insured*
If certificate is for an Entity, please list Entity name here
Policy Number
Your Name*
Phone*
Email*
Certificate Holder
Name of Certificate Holder*
Address*
Street Address Address Line 2 City State ZIP Code
Certificate Information
Policy to Include
- Commercial Liability
- Auto
- Umbrella
- Workers Compensation
- NY DBL
- Other (specify below)
Is the job in New York?*
- Yes
- No
Waiver of Subrogation required?
- Yes
- No
Are you sending us a copy of the insurance requirements? (attach file below)
- Yes
- No
If you have a digital copy of your insurance requirements please attach the file here
Max. file size: 50 MB.
Certificate Delivery
Insured’s Email
Certificate Holder’s Email
Additional Email(s)
List any special instructions for this certificate
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Insured Information

Certificate Holder

Certificate Information

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