Certificate of NYS Workers Compensation Insurance

Legal Name and Address of Insurance (Use street address only) Required Legal Name and Address of Insurace (Use street address only) is required.
Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e. a Wrap-up Policy) Optional
Business Telephone Number of Insured Required Business Telephone Number of Insured is required.
NYS Unemployment Insurance Employer Registration Number of Insured Required NYS Unemployment Insurance Employer Registration Number of Insured is required.
Federal Employer Identification Number Required Federal Emplyer Identification Number is required.
Name and address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Required name and address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) is required.
Name of Insurance Carrier Required Name of Insurance Carrier is required.
Policy Number Required You must provide a policy number.
Policy Effective Date Required Policy Effective Period is required.	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
Policy Expiration Date Required Policy Expireation Date is required.	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
The Proprietor, Partners or Executive Officers are: Required Undefined	All excluded or certain partners/officers excluded. Included. (Only check box if all partners/officers included)
Demolition is: Required Undefined	Excluded. Included.
Enter Validation Code Required

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