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Request Quote: New York State Workers Compensation Insurance Program

Company:
Address:
Address II:
City:
State:  
Contact Person:
Title:
Phone:
Fax:
Email:
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”

Please enter the text you see (case sensitive)