For the convenience of our brokers and Safety Group 580 members, we have compiled the most frequently requested forms, safety materials and other documents most relevant for nursing homes and assisted living facilities. Documents will automatically download, or the link will open in a new window for online viewing and download.
Relevant Workers’ Comp Forms
| Form | Description |
| UE-4 | Application for Workers’ Compensation Insurance |
| UE-4d | Application for Workers’ Compensation Insurance for Domestic Household Workers |
| U-3a | Assignment (Transfer) of Policy Interest Agreement |
| U-89 | Request for WC policy cancellation |
| U-111 | Request for Inclusion of Additional Interest |
| U-218 | Executive Officer Information Sheet |
| U-445 | Experience Rating Plan Request for Information |
| C2-F | First Report of Work-Related Injury/Illness |
| Info. Packet | Claimant Information Packet |
Didn’t find what you’re looking for? Find all NYSIF forms here or click on the link below.
NYSIF Forms & Online User Guides
NYSIF and HWG work together with brokers to create the lowest cost, highest-quality workers’ compensation packages for our clients. Contact us to work together.
The Hamilton Wharton Group 