Workers’ Compensation Commonly Used Forms

Frequently-used forms are available from the New York State for you to view online, print and complete.

U3 and U3a

U3 and U3a – New York State Insurance Fund Transfer of Policy Interest – Assignment of Interest Agreement Notice and includes U3a – Information on Entity for which Coverage is Requested

U111 and U111a

U111 and U111a – New York State Insurance Fund – Request for Inclusion of Additional Interest and includes U111a – Information on Entity for which Coverage is Requested

  • This form must be completed for each entity, including the FEINs, signed, and returned to NYSIF. Please have the form signed by a principal or an executive officer of the company you wish to add. No coverage will be issued if there is no combinability* between the entities. *Combinability – The same person, group of persons or corporation owns more than 50% of each entity.

U218

U218 – Executive Officer Information Sheet

Form U-218 must be completed and returned to NYSIF in every case where there is a change of officers of a corporation presently insured by us or where a request is made to transfer the policy to a corporation.

U617 and U619

U617 and U619 – Notice to Corporations with One or Two Executive Officers who own all of the Corporation’s stock. (Includes U619 – The notice of election of a corporation which is required to have coverage for its employees under the New Your State Workers’ Compensaiton Law to exclude the Sole Shareholder-officer or one of the two or both executive Officers-shareholders of the corporation from such coverage.)

  • Sole/Dual Executive Officer exclusion from workers’ compensation coverage

U626 and U627

U626 and U627 – Notice of Election of a Partnership, Limited Liability Partnership, Professional Limited Liability Partnership, Limited Liability Company, Professional Limited Liability Company or Sole Proprietorship to bring partners, members or self-employed persons under the coverage of the New York State Workers’ Compensation Law.

  • If you are self-employed (sole proprietor) or a partner as defined in Section 10 of the Partnership Law or a member of an LLC, you can elect to be covered under your policy by completing and signing the letter, U-626, and the notice of election form, U-627.
  • Return both to NYSIF.

U629

U629 – Notice of election of a Not-for-Profit Corporation or a Not-for-Profit Unincorporated Association to exclude an unsalaried executive officer from coverage pursuant to Section 54, subdivision 6 of the Workers’ Compensation Law.

  • A Not-for-Profit Corporation or a Not-for-Profit Unincorporated Association may exclude an unsalaried executive officer from coverage.

CPAP Application

635K – New York Workers Compensation Premium Credit Application

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