Forms Library

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

FormDescription
UE-4Application for Workers’ Compensation Insurance
UE-4dApplication for Workers’ Compensation Insurance for Domestic Household Workers
U-3aAssignment (Transfer) of Policy Interest Agreement
U-89Request for WC policy cancellation
U-111Request for Inclusion of Additional Interest
U-218Executive Officer Information Sheet
U-445Experience Rating Plan Request for Information
C2-FFirst Report of Work-Related Injury/Illness
Info. PacketClaimant 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.

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