ACORD 172 NY (7/96) – New York Notice of Election of a Partnership or Sole Proprietorship to Bring Partners or Self-Employed Persons Under the Coverage of the New York Workers’ Compensation Law

Use this form when a member of a partnership or a sole proprietor of a business elects to be included under workers compensation insurancecoverage.

This form must be retained by the workers compensationinsurance carrier. Copies must be sent to each person named in the form.