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FOR OFFICE USE ONLY

ATN:

_________________

N e w Y o r k S t a t e I n s u r a n c e F u n d

iCMS #: _________________

Workers' Compensation and Disability Benefits Specialist since 1914

Document Control Center, 1 Watervliet Ave. Extension, Albany, NY 12206

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)?

Name of Employer

Trade Name or Doing Business As Name

*Business Type

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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UE-4m (Revised 11-2011)

Form Ue-4m - Application For New York Workers' Compensation And Employers' Liability Insurance - New York State Insurance Fund