1. Requested effective date of insuranceThe earliest effective date is the day after you submit a fully completed application and the required deposit premium.Requested Effective Date* MM slash DD slash YYYY 12:01 AM, Eastern Standard Time2. Business (Employer) InformationPlease provide the following information about the business. When appropriate, include your DBA or TA name in the "Optional Information" section.Business Type*Corporation (For Profit)Corporation (Not For Profit)Corporation (Religious, Charitable, Educational and Veterans Organization)Co-PartnershipIndividualLimited Liability PartnershipLimited Liability CompanyProfessional Service Liability CompanyRegistered Limited Liability PartnershipPolitical SubdivisionOther – Please specifyPlease specify Business Name* Business Email* Business Telephone*Federal Tax ID*Don't have one? You can get an FEIN from IRS.GOVOptional InformationIs this a newly formed business?* Yes No Age of Business*3. Owner/Officer InformationName* First Last Title* Duties* Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Telephone*Email* Annual Salary*Cover this individual?* Yes No Second Owner Name First Last Second Owner Title Second Owner Duties Second Owner Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Second Owner Primary TelephoneSecond Owner Email Second Owner Annual SalarySecond Owner Cover this individual? Yes No Other OwnersPlease provide: Name, Title, Duties, Address, Phone, Email, Annual Salary, Cover this individual?4. Addresses & Work LocationsContact Information* First Last Mailing address of the employer.* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the Mailing Address the Main Work Location* Yes No List all New York business locations to be coveredA 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.Are there additional entities to be covered?* Yes No if yes, provide: Business Name, Business Name Business Email Business Telephone Federal Tax ID Optional Information.6. NYSIF HistoryHave any of the parties identified in questions 2, 3 and/or 5 ever been insured by the New York State Insurance Fund?* Yes No 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.List all previous New York State Insurance Fund policy numbers.Policy# and Approximate Coverage Dates 7. Other Workers' Comp Carrier HistoryHas the employer or any individual(s) listed in questions 2, 3 and/or 5 been insured for workers' compensation by a carrier other than the New York State Insurance Fund? If yes, please provide the employer's workers' compensation experience for the latest five years.* Yes No Upload loss runsMax. file size: 32 MB.7-1. Employer Rating HistoryIf known, please enter employer's NYCIRB number, latest experience modification factor and the effective rating date.NYCIRB # Experience Modification Factor Effective Rating Date MM slash DD slash YYYY 8. Business DescriptionDescribe business operationsIf 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 InformationPlease 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. DescriptionClerical Office EmployeesSalespersons/Collectors/MessengersExecutive Officers/Partners/Members/Self-EmployedOtherPlease Specify Subcontractor and Other Employer Information We use subcontractors, independent contractors or 1099 employees We lease employees to or from other employers