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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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NYSIF

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.
Requested Effective Date*
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.
Business Type*
Please specify
Business Name*
Business Email*
Business Telephone*
Federal Tax ID*
Don't have one? You can get an FEIN from IRS.GOV
Optional Information
Is this a newly formed business?*
- Yes
- No
Age of Business*
3. Owner/Officer Information
Name*
First Last
Title*
Duties*
Home Address*
Street Address Address Line 2 City 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 State ZIP Code
Second Owner Primary Telephone
Second Owner Email
Second Owner Annual Salary
Second Owner Cover this individual?
- Yes
- No
Other Owners
Please provide: Name, Title, Duties, Address, Phone, Email, Annual Salary, Cover this individual?
4. Addresses & Work Locations
Contact Information*
First Last
Mailing address of the employer.*
Street Address Address Line 2 City State ZIP Code
Is the Mailing Address the Main Work Location*
- Yes
- No
List all New York business locations to be covered
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.
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 History
Have 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 History
Has 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 runs
Max. file size: 32 MB.
7-1. Employer Rating History
If 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 Description
Describe business operations
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.
Description
Please Specify
Subcontractor and Other Employer Information
- We use subcontractors, independent contractors or 1099 employees
- We lease employees to or from other employers

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1. Requested effective date of insurance

2. Business (Employer) Information

3. Owner/Officer Information

4. Addresses & Work Locations

5. Other Businesses (Entities)

6. NYSIF History

7. Other Workers' Comp Carrier History

7-1. Employer Rating History

8. Business Description

9. Payroll Information