Electronic Workers' Compensation Application for Brokers

NYSIF now has an electronic application for insurance brokers, allowing producers the ability to fill out applications on behalf of their clients, while allowing clients to digitally sign the application and pay premium deposits online.

Brokers, agents and representatives can use NYSIF’s eApplication for new workers’ compensation policies in a few easy steps.

All applications must be fully completed, signed by the client and be accompanied by the premium deposit. Brokers or clients have the option to pay premium deposits electronically.

To apply for workers’ compensation insurance use NYSIF eQuote. If your client is not a new business, NYSIF requires loss runs for the last five years and at least one of the following items of payroll verification to accompany the application:

  • A copy of your previous insurance carrier’s premium audit bill showing classifications and payrolls for the most recent policy period;
  • Copies of Federal Tax Form 941 for the last four quarters;
  • Copies of New York State Tax Form NYS-45-MN quarterly combined withholding, wage reporting and unemployment insurance return for the last four quarters.

If approved, coverage becomes effective at 12:01 a.m., Eastern Standard Time, the day after NYSIF receives the application and premium deposit, or any subsequent date requested. You and your client will receive notification of the policy number, the effective date of coverage, policy declaration and information pages.

If you are unable to use NYSIF eQuote, you can print the following applications and supplemental questionnaires. If approved, coverage becomes effective at 12:01 a.m., EST, the day following the postmark of your mailed application and premium deposit.

Workers' Compensation Insurance Application
Building Demolition
Roofing Contractors
Volunteer Firefighters Application
Volunteer Ambulance Workers Application

Adobe Reader is required to view one or more of these documents. You may download Adobe Reader by clicking on the button below.

Get Adobe Reader