We help business owners navigate New York workers' comp rules.

Welcome to our New York forms and guide page. We make every effort to provide you with free and direct access to the most common insurance forms, accords, and guides related to New York workers' comp coverage. We update our forms regularly so you have the most recent documents available. Please contact one of Our NY Specialists if you have a question or need help with a particular New York comp form.

New York State Workers' Compensation Board is responsible for administering the NY worker comp program under the direction of the New York Department of Insurance. NY is not an NCCI state and, therefore, develops its own unique manuals and rules regarding workers' compensation classifications and experience modifications factors.

New York Workers' Compensation Insurance Forms

NY Acord 130 Workers' Compensation Application

The standard Acord 130 application form for workers' comp coverage in New York.

New York First Report of Injury Form

NY First Report of Injury Form.  Employers should complete this form and send to their insurance company each time an injury occurs.

New York Surcharge Descriptions

This document provides detail information regarding workers' compensation in New York.

New York Workers' Compensation and Employers Liability Manual

This form details the Assessment charges for New York workers' compensation programs.

Workers' Compensation Employee Claim Form

Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type or print neatly. This form may also be filled out on-line at www.wcb.state.ny.us.

Workers' Compensation Employee Claim Information Packet

This packet contains the application material to file a claim, and provides greater detail about filing a claim.

NY Election to Exclude Spouse

Sole-proprietorships, regular partnerships, individual trustees, individual receivers and legal representatives may be eligible for spousal exemptions. Corporations, LLCs, LLPs, LPs, PLLCs, PLLPs, RLLCs, RLLPs, Joint Ventures, associations, unions, and nonprofits are NOT eligible for spousal exemptions.

New York Workers' Compensation Exemption Form

Use this form if you are not required to carry workers' compensation and/or disability benefits insurance.

New York Rejection of Workers' Compensation Coverage Form

Notice of election of a corporation which is required to have coverage for its employees under the New York state workers' compensation law to exclude the sole shareholder-officer or one of the two or both executive officers-shareholders of the corporation from such coverage.

What Employers Need to Know About Workers' Compensation

This is a document containing an overview of information pertaining to New York workers' compensation.

New York Notice to Reduce or Discontinue Payments

Form for the reduction or discontinuation of Workers' Compensation in New York.

Voluntary Agreement Form

Employer/Respondents form for confirmation of claim information and verification of the validity of the claim.

New York Notice of Election Form

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 person under the coverage of the New York state workers' compensation law.

New York Workers' Compensation Employer Handbook

A Guide to the Workers’ Compensation and the Disability Benefits Systems for the New York State Business Owner.

Employee Statement of Exempt Status

Complete this form if you are receiving old-age insurance benefits under Section 235 of the Social Security Act.

Workers' Comp Exemption

Each state has its own laws and requirements regarding when and how employers are allowed to opt-out of coverage under their workers' compensation policy. Some states make it easier than others because they don't require anything to be filed. Other states require special inclusion or exclusion affidavit documentation. Failure to comply often causes employers to have to pay premium on themselves even when they wanted to be excluded form coverage.

Waiver of Subrogation

A waiver of subrogation means that a business and their insurance company is foregoing all rights to file suit, or seek damages, from another business. This is common in the construction industry as builders attempt to protect their company from negligence. A workers' comp waiver of subrogation does not prevent an injured employee from filing a lawsuit for damages. This coverage typically add about $100 to the cost of a work comp policy.

Certificate of Insurance

A Certificate of Insurance is a document that serves as evidence of insurance or proof of coverage. Certificates indicate your current coverages and policy limits. Insurance Agencies issue on an insured's behalf and they often list a third party as a certificate holder. This means they should be notified if a policy cancels prior to expiration. Requests for any special wording should be carefully checked against the policy language before being added to a certificate as they can create legal issues with coverage.


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Find Affordable Workers' Comp Programs in Your State

New York Compensation Insurance Rating Board

200 East 42nd Street
New York, NY 10017
212-697-3535
NYCIRB

New York State Insurance Department

Rockefeller Empire State Plaza
Agency Building One
Albany, NY 12257
Department of Financial Services

New York State Workers' Compensation Board

20 Park Street
Albany, NY 12207
518-474-6670
NY Workers' Compensation Board

New York State Insurance Fund- SIF

1 Watervliet Ave Ext.
Albany, NY 12206
518-437-6400
NYSIF

New York is not an NCCI as they are under the jurisdiction of NYCIRB. The state has its own State Insurance Fund (SIF) which is a non-profit agency that operates separately from other state workers' comp agencies.

The New York State Fund (SIF) is the insurance carrier of last resort in NY and must provide access to legally required workers' compensation coverage to all employers in New York. The may only deny coverage if an employer owes a previous balance.

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Visit NCCI for more resources and information about workers' compensation class codes. Visit United States Department of Labor for more information about government agencies managing workers compensation insurance rates.

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