Other Owners Please provide:
Name,
Title,
Duties,
Address,
Phone,
Email,
Annual Salary,
Cover this individual?
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.
List all previous New York State Insurance Fund policy numbers. Policy# and Approximate Coverage Dates
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.
