Ny acceptance form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the name of the insurance carrier at the top of the form. Ensure that you are authorized to act on behalf of the carrier.
3. In section 1, select the type of attached form (Policy, Rider, Supplement, or Other) and provide any necessary specifications.
4. Complete section 2 by entering the date this form was filed with the Superintendent of Insurance and include the Insurance Carrier's Form Number.
5. For section 3, list any additional insurance carrier forms that will be used alongside this one, including their identifying numbers.
6. In section 4, check all applicable boxes that describe the benefits provided by this form as per Section 204 of the Workers' Compensation Law.
7. Finally, sign and date at the bottom of the form as an authorized representative and provide your contact number and title.

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