New York Associate Representation Form

State:
New York
Control #:
NY-SD-790
Format:
PDF
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Description

Associate Representation Form

The New York Associate Representation Form is a type of legal document used in the state of New York that allows an employer to designate a designated representative to act on their behalf regarding the employer’s workers' compensation insurance policy. This document serves to provide the employer with legal protection and safeguards in the event of a claim. Different types of New York Associate Representation Form include: Designation of Associate Representation Form, Employer Designation of Associate Representation Form, and Designation of Associate Representation Form for Self-Insured Employers. This document requires information such as the employer’s name, address, contact information, insurance policy information, and the name and contact information of the designated representative. Once completed, the form must be signed and notarized.

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Charles L. Brieant Jr. Federal Building and Courthouse 300 Quarropas Street White Plains, NY 10601. To be appointed as the applicant's representative, the case manager must complete the SSA-1696: Appointment of Representative form.Use this form to change information related to the owner, attorney, or representative. Completion of this form is voluntary; however, if you want to use this form to appoint someone to act on your behalf in matters before the Social Security. License Application. Application For Sales Representative- Lt-426 ; Duration of License. Checklist: Get Prepared for the Loan Process. Subject to certain exceptions, the Privacy Rule at 45 CFR 164. Print and complete the Appointment of Representative form below. Subject to certain exceptions, the Privacy Rule at 45 CFR 164.

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New York Associate Representation Form