Skip to main content
New York State Insurance Fund Logout

  1. Policy Info
  2. Business Info
  3. Payroll Info
  4. Review Info
  5. DocuSign Ceremony
  6. Report Filed

Policy Information

Customer Information

NOTE: Please note that you will be redirected to the website of DocuSign for authentication, signature and completion of this document. As part of this process you may be asked to respond to questions that confirm your identity as the person submitting these payroll figures.

I agree to the New York State Insurance Fund User Agreement and Privacy Policy.

You will need Adobe Reader 8 or higher if you choose to print this form for mailing. If you don't have Adobe you can get the latest version by clicking the image.
Adobe Reader