yellow tick  Broker Requirements

In order for Keevily to help you provide cost effective, high-quality NY Workers' Compensation insurance options to your clients, please submit the following information:

  1. Acord Commercial Application 125 and Workers’ Comp App 130; or current carrier Declarations page. If insured in State Fund Group 90, please submit State fund completed State declarations page Insurance Fund application
  2. Latest Worker’s Compensation Policy Information Page/Declarations Page
  3. Latest Worker’s Compensation Audit Billing
  4. 5 Year Loss History
  5. Provide Information on Additional Entities
  6. Please let us know if this account has previously been insured with the State Insurance Fund.

Contact Dina Bonifacio for a quote

Business submissions:

Dina Bonifacio 800-523-5516 Email: Fax: 914-381-1134

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