Ue 4M Form – Fill Out and Use This PDF

APPLICATION FOR NEW YORK WORKERS’ COMPENSATION AND EMPLOYERS’ LIABILITY INSURANCE

Any person who wilfully makes a false statement or representation, deliberately conceals any material fact, or engages in any other fraudulent scheme or device, for the purpose of obtaining or attempting to obtain, or for the purpose of aiding or abetting any person to obtain insurance in the New York State Insurance Fund at less than the proper rate for such insurance, or payment out of the New York State Insurance Fund to which such person is not entitled, is guilty of a crime. 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.

Applicant, please note:

Application 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.

PLEASE PRINT YOUR ANSWERS.

(1)REQUESTED EFFECTIVE DATE OF INSURANCE: _____/_____/________ 12:01 A.M., EASTERN STANDARD TIME.

(2)WHAT IS THE FULL NAME(S) OF THE EMPLOYER(S) INCLUDING ANY TRADE NAME(S) OR DOING BUSINESS AS NAME(S)?

Attach a separate sheet if additional space is needed.

For each additional employer listed, required forms establishing all such employers meet the requirements to be written under a single policy must be submitted.

*Business types: Sole Proprietor/Self Employed; Partnership; Corporation; Political Subdivision; Limited Liability Company; Professional Service Liability Company; Registered Limited Liability Partnership; Limited Liability Partnership; or if Other-Specify.

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(3)PLEASE PROVIDE THE MAIN NEW YORK STATE WORK LOCATION OF THE EMPLOYER:

(P.O. BOX IS NOT ACCEPTABLE AS A WORK LOCATION)

For the purpose of serving notice of cancellation in accordance with section 54(5) of the New York Workers’ Compensation Law, the insured(s) agree(s) that service of notice upon the person or entity designated at the address specified is service of notice upon all insureds insured under one insurance policy. All bills, correspondence and other mailed material also will be sent to that person or entity at that address. If an employer identifies a mailing address that is different from the work location address, NYSIF will deem the mailing address the “last known place of business” for cancellation notice purposes.

(4a) IF YES, PLEASE ENTER INFORMATION ON YOUR REPRESENTATIVE:

(6a) IF YES, PLEASE PROVIDE INFORMATION ON YOUR WORKERS’ COMPENSATION EXPERIENCE FOR THE PAST 5 YEARS:

(7)IF KNOWN, PLEASE ENTER YOUR RATING BOARD FILE NUMBER, LATEST EXPERIENCE MODIFICATION FACTOR AND THE EFFECTIVE RATING DATE:

Attach a separate sheet if additional space is needed.

(You must answer “YES” if you or any person who directly or indirectly owns or controls or is the president, vice president, secretary or treasurer of an employer identified in Question (2) either directly or indirectly owns or controls or is president, vice president, secretary or treasurer of an employer that has had a workers’ compensation policy with the State Insurance Fund that was cancelled, or directly or indirectly owned or controlled or was president, vice president, secretary or treasurer of an employer at the time that employer’s workers’ compensation insurance policy with the State Insurance Fund was cancelled. The Workers’ Compensation Law prohibits any person from contracting for a subsequent policy with the State Insurance Fund while the billed premium on such a cancelled policy remains uncollected.)

(9a) IF YES, PLEASE COMPLETE:

Previous State Fund Policy Number	Period of Coverage
	From:	/	/	To:	/	/
	From:	/	/	To:	/	/
Attach a separate sheet if additional space is needed.

(10) PLEASE DESCRIBE YOUR BUSINESS OPERATIONS INCLUDING THE PRODUCTS OR SERVICES SOLD:

If you are a manufacturer, include the raw materials, processes, products, and equipment used or produced. If you are a contractor or engage in construction then describe the type of work performed including the work performed by sub-contractors. If engaged in mercantile, wholesale or retail trade, describe the merchandise sold, types of customers and deliveries. If engaged in a service business, describe the type of service performed and location(s) of such service. If engaged in farming, include acreage, types and numbers of animals, machinery used and sub-contracts.

Business Description	(Attach a separate sheet if additional space is needed.)

(11) PLEASE LIST YOUR ESTIMATED ANNUAL PAYROLL BY TYPE OF WORK OR DUTIES FOR ALL YOUR EMPLOYEES:

If you are a corporation with one or two executive officers who collectively own 100% of the corporation’s stock, you have the option to exclude the officers from coverage.

If you are a partnership, LLP, PLLP, LLC, PLLC or Sole Proprietorship you can elect to bring partners, members or self-employed persons under coverage for a premium that is subject to a minimum and maximum annual remuneration.

DO YOU WISH TO INCLUDE PARTNERS, MEMBERS OR SELF-EMPLOYED PERSONS?

YES

NO

If yes, include remuneration for person(s) you wish to bring under coverage on the next page and required forms must be submitted.

New York State Insurance Fund Workers’ Compensation and Employers’ Liability Application

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QUESTION (11) CONTINUED

Description	Duties	# of	Annual Payroll
		Employees
CLERICAL OFFICE EMPLOYEES

SALESPERSONS / COLLECTORS / MESSENGERS

EXECUTIVE OFFICERS / PARTNERS / MEMBERS /

SELF-EMPLOYED

OTHER-DESCRIBE

OTHER-DESCRIBE

OTHER-DESCRIBE

(P.O. BOX IS NOT ACCEPTABLE AS A LOCATION. ONLY NEW YORK STATE LOCATIONS CAN BE COVERED.)

NY

NY

Attach a separate sheet if additional space is needed.

(14) ADDITIONAL INFORMATION ON THE EMPLOYER(S) SEEKING COVERAGE, LISTED IN QUESTION (2):

Attach a separate sheet if additional space is needed.

(15) WHAT IS THE NAME AND ADDRESS OF YOUR BANK?

(16) INFORMATION ON THE PERSON YOU WISH US TO CONTACT FOR A PREMIUM AUDIT:

Name:

(17)PLEASE PROVIDE INFORMATION ON THE SOLE PROPRIETOR, ALL EXECUTIVE OFFICERS, PARTNERS, ELECTED OR APPOINTED OFFICIALS, OR MEMBERS OF GOVERNING BOARDS, IF APPLICABLE:

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(17a) ARE ANY OF THE INDIVIDUALS LISTED IN QUESTION (17) PARTNERS OR CORPORATE OFFICERS FOR A PARTNERSHIP OR

CORPORATION OTHER THAN THE EMPLOYER(S) SPECIFIED IN QUESTION (2)?

YES

NO

(17b) IF YES, LIST THE NAME(S) OF ALL SUCH INDIVIDUALS WITH THEIR PRINCIPAL BUSINESS ADDRESS AND, FOR A CORPORATION, THE PERCENTAGE OF STOCK OWNERSHIP.

Address:

Attach a separate sheet if additional space is needed.

Attach a separate sheet if additional space is needed.

(21) IF YOU ARE INCORPORATED, HAVE THE PRINCIPALS OF THE CORPORATION PREVIOUSLY MANAGED A BUSINESS BY ANOTHER

NAME?

YES

NO

(21a) IF YES, PLEASE COMPLETE:

Attach a separate sheet if additional space is needed.

New York State Insurance Fund Workers’ Compensation and Employers’ Liability Application

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(23a) IF YES, PLEASE DESCRIBE OTHER BUSINESS OPERATIONS INCLUDING THE PRODUCTS AND SERVICES SOLD:

Business Description	(Attach a separate sheet if additional space is needed.)

(25)PAYROLL VERIFICATION:

(This requirement does not apply to employers of domestic workers or to municipalities or other political subdivisions.)

At least one of the following items of payroll verification MUST accompany this application. Failure to provide payroll verification may result in rejection of your application for insurance. Please attach at least one of the following items to your application:

A copy of your previous insurance company’s premium audit bill showing the 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 none of the foregoing documents are available because you are a new business or did not have employees, then check this box:

New York State Insurance Fund Workers’ Compensation and Employers’ Liability Application

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(26)I UNDERSTAND THAT THE INFORMATION WHICH I HAVE PROVIDED ON THIS APPLICATION WILL BE USED TO CALCULATE MY WORKERS’ COMPENSATION INSURANCE PREMIUM. I ALSO UNDERSTAND THAT I HAVE A CONTINUING OBLIGATION TO NOTIFY THE NEW YORK STATE INSURANCE FUND OF ANY CHANGES IN:

THE KINDS OF WORK WHICH THE BUSINESS IS DOING

THE SIZE OF OUR WORKFORCE

THE SIZE OF OUR PAYROLL

THE BUSINESS OWNERSHIP OR BUSINESS STRUCTURE

PLEASE PRINT, SIGN AND MAIL YOUR COMPLETED APPLICATION ALONG WITH THE REQUIRED DEPOSIT

Applicant, please note:

INFORMATION YOU PROVIDE IS PROTECTED BY THE PERSONAL PRIVACY PROTECTION LAW

The authority to obtain the personal information requested herein is found in Section 83 of the Workers’ Compensation Law as supplemented by Sections 450.1,

450.3and 450.5 of Chapter VI of Title 12( c ) of the Official Compilation of Codes, Rules and Regulations of the State of New York. The principal purpose for which the information is sought is to assist the New York State Insurance Fund in processing your insurance coverage with the New York State Insurance Fund and its release is governed by the limitations of the Personal Privacy Protection Law. This information will be maintained by the Director of Underwriting, New York State Insurance Fund, 199 Church Street, New York, NY 10007.

To ensure prompt service and processing, please mail your fully completed and signed application along with your deposit premium check and supporting documentation to:

NEW YORK STATE INSURANCE FUND DOCUMENT CONTROL CENTER – NEW BUSINESS 1 WATERVLIET AVENUE EXTENSION

ALBANY, NY 12206

For additional assistance, customer service and contact information:

Please visit our website at WWW.NYSIF.COM or telephone us at 1-888-875-5790

New York State Insurance Fund Workers’ Compensation and Employers’ Liability Application

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