1. Requested effective date of insurance
The earliest effective date is the day after you submit a fully completed application and the required deposit premium.
MM slash DD slash YYYY
12:01 AM, Eastern Standard Time
2. Business (Employer) Information
Please provide the following information about the business. When appropriate, include your DBA or TA name in the "Optional Information" section.
Don't have one? You can get an FEIN from IRS.GOV
3. Owner/Officer Information
Cover this individual?
4. Addresses & Work Locations
A post office box (P.O. Box) is not acceptable as a location. Only New York State locations can be covered.
5. Other Businesses (Entities)
List all other businesses (employers) that you are seeking to cover under this policy. This means any business requiring coverage under this policy that operates under a different FEIN (Federal Employer Identification Number) and/or a separate set of payroll records. For each additional business listed, required forms must be submitted to determine whether it meets the requirements to be written under a single policy.
6. NYSIF History
Answer yes to include if any person or entity which owns, controls or has a majority interest in any employer identified in questions 2, 3 and/or 5, also owned, controlled or was an officer of another employer that was previously insured with the New York State Insurance Fund.
Policy# and Approximate Coverage Dates
7. Other Workers' Comp Carrier History
7-1. Employer Rating History
If known, please enter employer's NYCIRB number, latest experience modification factor and the effective rating date.
MM slash DD slash YYYY
8. Business Description
If the employer is a manufacturer include the raw materials, process, products and equipment used or produced. If the employer is a contractor or engaged in construction then describe the type of work performed including the work performed by subcontractors. If engaged in merchandise, wholesale or retail trade, describe the merchandise sold, types of customers and deliveries. If engaged in a service business describe the type of service performed and location(s) of such service. If engaged in farming include acreage, types and numbers of animals, machinery used and subcontracts.
9. Payroll Information
Please list your estimated annual payroll by the type of work and duties for all your employees. If the official(s) has elected to be excluded from coverage, do not include their annual payroll.