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Business Relationship












Workers' Compensation Policyholder Identity Verification

Please provide the following information as shown on the information page of your policy.

(for example: enter A123-4567-8 as 12345678)
Enter both letter and digits
(mm/dd/yyyy)
(mm/dd/yyyy)
Enter digits only
Broker Identity Verification

Please provide the following information as shown on the most current Information Page for any three policies under your management.
Be sure to enter document numbers correctly, they are case-sensitive.

Must be numeric
Policy 1 Policy 2 Policy 3
* Policy Number            
* Document Number      
* Period Covered End Date                  
Group Number            
Disability Benefits Services
(Enter numbers only (no dashes).)
Enter numbers only (no dashes).
(Enter numbers only (no dashes).)
Enter numbers only (no dashes).
(Zip for Disability Benefits Account)
NYSIF Medical Payee Verification
(mm/dd/yyyy)
(mm/dd/yyyy)
(Zip for Primary Payment Address)
Contact Information
*
*
(example: 12345)
example: 12345
(example: 1234)
example: 1235
(numbers only - with area code)
(numbers only - with area code)
Choose your username and password
Your password must be at least 8 characters and at least one non-alphabetic character. special characters [&*^(){}] are not allowed.

Please type the word you see in the picture bellow:

Terms and Conditions