Get Nylr 1 - New York Compensation Insurance Rating Board - Nycirb

The NYLR 1 form is an essential document for individuals and organizations opting into the Retrospective Rating Plan for Workers' Compensation in New York. This guide will provide you with step-by-step instructions on how to fill out this online form accurately and efficiently.

Follow the steps to complete the NYLR 1 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the name of the insured in the designated space.
3. Enter the address of the insured clearly, ensuring all details are accurate.
4. Specify the name of the insurance carrier handling the policy.
5. Input the policy number(s) relevant to the insured.
6. Indicate the effective date of the retrospective rating plan.
7. Choose the term of the plan by checking one of the options: One-Year, Three-Year, or Wrap-up.
8. List the line(s) of insurance covered under this plan.
9. Complete the estimated annual premiums: a. for New York WC Standard Premium, b. for States Other Than NY, and c. for All Lines Other Than WC.
10. Fill in the retrospective rating values, including maximum and minimum premium factors, net variable expense factor, and tax multiplier.
11. Indicate the WC loss limitation factor along with other necessary loss limits and bases.
12. If applicable, specify any special conditions related to the elected plan.
13. Ensure the form is signed by the insured, which may be the proprietor, partner, or an authorized officer.
14. Sign the form as a carrier representative if required.
15. Finally, make sure to save changes, download, print, or share the completed form as necessary.

Take action today and complete your NYLR 1 form online for a smoother application process.