Broker Requirements

In order for Keevily to help you provide cost effective, high-quality NY Workers’ Compensation insurance options to your clients, please submit the following information:

  1. Acord Commercial Application 125 and Workers’ Comp App 130; or current carrier Declarations page. If the insured is in State Fund Group 90, please submit the most recent declaration
  2. Latest Worker’s Compensation Audit Billing
  3. 5 Year Loss History
  4. Provide Information on Additional Entities
  5. Please let us know if this account has previously been insured with the State Insurance Fund.

Contact us for a quote
Business submissions:
800-523-5516 Fax: 914-381-1134