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Essential worker nys form

New york exclude officer 2026

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The document outlines the process for revoking the election of a not-for-profit corporation or unincorporated association to exclude an unsalaried executive officer from coverage under New York's Workers' Compensation Law. It details the necessary steps, including certification by the Board of Directors, and specifies that the revocation becomes effective 30 days after filing with the Workers' Compensation Board and insurance carrier.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the name and address of your insurance carrier in the designated fields at the top of the form.
Next, provide the name of your corporation or association along with its address. If applicable, indicate under which state laws it is incorporated.
Fill in the details of the executive officer you wish to include in the policy, including their name and title.
Certify that this revocation was made during a board meeting by signing and typing your name and title in the appropriate sections.
If your corporation has a seal, affix it; if not, check the provided box. Finally, include a contact telephone number for any follow-up.

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