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Workers' Compensation

Select the insurance program you need to get a quote.

Workers' Compensation Disability & FMLA

Workers' Compensation Insurance Program

Company

Contact Person

Title

Phone

Fax

Address

Address II

City

Zip

Current Insurance Carrier

Or Self Insured/Trust

Renewal Date

Number of Employees

Codes & Payroll Estimates

Experience Modification and or RB File #

(Construction Only), PAP Credit

To receive accurate and up-to-date information regarding your potential Workers’ Compensation Insurance coverage, please provide us with the following:

Number of business locations and the number of employees at each location
3 year payroll audits*
5 year loss runs by year*
5 year premium history*

* Depending on how long the company has been in the business ** Note: If you consider obtaining an individual insurance, i.e. non-group one, in addition to the above, please complete " NYSIF: Application for New York Workers' Compensation and Employers' Liability Insurance"