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Business Relationship
*

Workers' Compensation Policyholder Identity Verification

Please provide the following information as shown on the most recent Information Page of your policy.

(for example: enter A123-4567-8 as 12345678)
Enter both letter (case-sensitive) and digits.
*
Enter digits only
Broker Identity Verification
Must be numeric
(for example: enter A123-4567-8 as 12345678)
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
 
*
(Zip for Primary Payment Address)
Contact Information
*
*
(example: 12345)
(example: 1234)
(numbers only - with area code)
(numbers only - with area code)
 
*
Choose your username and password
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