Effective Date

Requested Effective Date of Insurance(Required)

Earliest effective date may be no sooner than 1 week after this for is submitted to NYPA for submittal.

Employer Information

Business Type(Required)

Please specify your business type(Required)

Business Name(Required)

Business Email(Required)

Business Telephone(Required)

Federal Tax ID(Required)

Is this a newly formed business(Required)

Yes

No

This business has no prior coverage and payroll history and has not operated under another entity.

Age of Business (Years)(Required)

Months(Required)

Owner/Officer Information

List all proprietors, executive officers, partners, elected or appointed officials, or members of governing boards regardless of their individual coverage needs.

Name(Required)

First Last

Title(Required)

Duties(Required)

Phone(Required)

Email(Required)

Annual Salary(Required)

Cover this individual?(Required)

Yes

No

Additional Owner Information (if applicable)

Include first and last name of addtional owners if applicable.

Addresses & Work Locations

Employer Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Business Location(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Business Location(s)

List the address of all New York Business Locations to be covered

Other Businesses

Please list any other businesses that you are seeking to cover. These businesses would include employers that operate under a different FEIN or separate payroll records.

Business Information

For each business, please include Business Type, Business Name, Telephone and Federal Tax ID.

Workers Comp History

Note: Prior unpaid policies with NYSIF may affect policy issuance.

Have employer(s) seeking coverage or their employer owners been insured for worker's compensation? If yes, please provide the employer's workers' compensation experience for the latest five years(Required)

Yes

No

Most Recent Policy Year

Please enter a number from 2020 to 2050.

Annual Premium

Loss Incurred (If applicable)

Copy of loss runs and audit bills from prior insurer (if applicable)

Max. file size: 64 MB.

Add additional policy history?

Additional Policy Year #1

Policy Year

Please enter a number from 2020 to 2050.

Annual Premium

Loss Incurred (If applicable)

Additional Policy Year #2

Policy Year

Please enter a number from 2020 to 2050.

Annual Premium

Loss Incurred (If applicable)

Additional Policy Year #3

Policy Year

Please enter a number from 2020 to 2050.

Annual Premium

Loss Incurred (If applicable)

Additional Policy Year #4

Policy Year

Please enter a number from 2020 to 2050.

Annual Premium

Loss Incurred (If applicable)

Employer Rating History

If known, please include the employer's NYCIRB number and related rating information below.

NYCIRB #

Experience Modification Factor

Effective Rating Date

Business Description

Be as thorough as possible when entering your business description. Include all aspects and operations of your business.

Describe Business Operations(Required)

Payroll Information

List estimated annual payroll. If owners are excluded from coverage, do not include their annual payroll.

Payroll Details

Include a payroll description, duties, number of employees, and annual payroll for each payroll group. You may include an spreadsheet below if it contains the needed information instead of filling this field.

Payroll Spreadsheet (optional)

Drop files here or

Accepted file types: , xls, xlsx, csv, Max. file size: 64 MB.

Include a spreadsheet of payroll details as outlined in the field above.

NYS Form NYS-45-MN and/or federal Form 941 for the last four quarters(Required)

Max. file size: 64 MB.

Casual labor, 1099 forms and any payments to uninsured subcontractors

Max. file size: 64 MB.

Subcontractor and Other Employer Information

If you hire or lease an employee who is not covered by a valid worker's compensation policy, you will be liable for their coverage. Please let us know if there are any such workers regardless of their coverage.

Contractor Details(Required)

We use subcontractors, independent contractors, or 1099 employees

We lease employees to or from other employers

N/A

Worker's Comp Quote Request

Effective Date

Employer Information

Owner/Officer Information

Addresses & Work Locations

Other Businesses

Workers Comp History

Employer Rating History

Business Description

Payroll Information

Subcontractor and Other Employer Information