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Includes fraud warning and explains that coverage depends on receipt of required deposit premium and acceptance by NYSIF with an inception date. Collects requested effective date, detailed business information, and details for sole proprietors, officers, partners, and governing board members, including addresses, contact data, and whether individuals are covered.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/application-for-new-york-workers-compensation-and-employers-liability-insurance/304774/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/application-for-new-york-workers-compensation-and-employers-liability-insurance/304774.png","ImageObject",442,249,{"name":88,"@type":89},"Violet","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"When does insurance coverage take effect for a submitted application?","Question",{"text":108,"@type":109},"Coverage is tied to the policy acceptance by the New York State Insurance Fund and is evidenced by the inception date. 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In addition, the New York State Insurance Fund shall have a right of action to recover civil damages equal to three times the amount wrongfully obtained, or five thousand dollars, whichever is greater. This right of action is in addition to any other remedy provided by law.  \nApplicant, please note:  \nApplication is hereby made to the NEW YORK STATE INSURANCE FUND for a policy insuring the applicant's liability for the payment of benefits to the applicant's employees under the New York Workers' Compensation Law. No coverage will be effected unless the required deposit premium is received along with this application. Applicant understands that no liability shall attach to the NEW YORK STATE INSURANCE FUND under this application and that insurance shall not be effective unless and until this application is accepted by the NEW YORK STATE INSURANCE FUND as evidenced by the inception date indicated in a policy, the terms and provisions of which will be binding upon the applicant. Applicant further understands that a policy of insurance issued pursuant to this application will not extend coverage under the Disability Benefits Law, the Volunteer Firefighters' Benefit Law or the Volunteer Ambulance Workers' Benefit Law; any liabilities of the applicant under such laws to employees, executives or others must be separately insured under a Disability Benefits insurance policy, Volunteer Firefighters' Benefit Law policy or Volunteer Ambulance Workers' Benefit Law policy for which separate applications must be submitted.  \n(1)* REQUESTED EFFECTIVE DATE OF INSURANCE:   /  /   12:01 A.M., EASTERN STANDARD TIME. The earliest effective date is the day after you submit a fully completed application and the required deposit premium.  \n(2)* PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE BUSINESS. WHEN APPROPRIATE, INCLUDE YOUR DOING BUSINESS AS NAME OR TRADING AS NAME.  \nBusiness Type:*    \nBusiness types: Sole Proprietor/Self Employed; Partnership; Corporation (For Profit); Corporation (Not For Profit); Corporation (Religious, Charitable, Educational and Veterans Organization); Political Subdivision; Limited Liability Company; Professional Service Liability Company; Registered Limited Liability Partnership; Limited Liability Partnership; or if Other-Specify.  \nBusiness Name:*  \n________________________________________________________________  \nDBA or TA Name:  \n________________________________________________________________  \n(Circle one)  \nFederal Tax ID:*   NYS Unemployment Ins. \\#:   NAICS CODE:    \nBusiness Telephone   Business Fax:    \nWebsite:   Business email address:    \n*Required Field  \n(2a)* IS THIS A NEWLY FORMED BUSINESS?   YES   NO  \n(2b) IF YOU ARE A CORPORATION, IN WHAT STATE ARE YOU INCORPORATED? DATE OF INCORPORATION?  \nState:   Date of Incorporation:   /  /   \n(2c)* HOW LONG HAS YOUR COMPANY BEEN IN BUSINESS? Years:   Months:    \n(3)* PLEASE PROVIDE INFORMATION ON THE SOLE PROPRIETOR, ALL EXECUTIVE OFFICERS, PARTNERS, ELECTED OR APPOINTED OFFICIALS, OR MEMBERS OF GOVERNING BOARDS, IF APPLICABLE. LIST ALL SUCH PERSONS, REGARDLESS OF WHETHER THEY WILL BE COVERED. (Attach a separate sheet if additional space is needed.)  \n(3a)* First Name:*   MI:   Last Name: *    \nTitle: *   Duties:*   \n(President, Vice-President, Secretary, Treasurer,  \nMember, Chairperson, Owner, Partner, Other-Specify)  ","cbCaij1rHxRMASW4","https://ap.wps.com/l/cbCaij1rHxRMASW4","pdf",218991,6,"English","# Application overview\n## Fraud and coverage conditions\n# Requested effective date\n# Business information\n## Business type and identifiers\n## Newly formed business and incorporation details\n## Company time in business\n# Applicant and covered individuals\n## Sole proprietor and governing persons\n# Employer mailing and work locations","[{\"question\":\"When does insurance coverage take effect for a submitted application?\",\"answer\":\"Coverage is tied to the policy acceptance by the New York State Insurance Fund and is evidenced by the inception date. The earliest effective date is the day after a fully completed application and the required deposit premium are submitted.\"},{\"question\":\"What information must be provided about the business?\",\"answer\":\"The form requests business type selection and identifying details such as business name, DBA/TA name, federal tax ID, NAICS code, phone/fax, website, and business email. It also asks whether the business is newly formed and, if applicable, the incorporation state and date, plus how long the company has been in business.\"},{\"question\":\"Who must be listed as individuals for coverage consideration?\",\"answer\":\"The application requires information on the sole proprietor, executive officers, partners, elected or appointed officials, or governing board members, listing all such persons regardless of whether they will be covered, along with contact details and whether each individual is covered.\"}]","APPLICATION FOR NEW YORK WORKERS’ COMPENSATION AND EMPLOYERS’ LIABILITY INSURANCE | PDF",1789817149]