ACORD 173 NY Instructions

ACORD 173 NY (7/96) – New York Notice of Election of an Incorporated Religious, Charitable, Educational, or U.S. War Veterans Organization to Bring Executive Officers Under the Coverage of the New York Workers’ Compensation Law

Use this form when any executive officer of an incorporated religious, charitable, educational or U.S. war veterans organization elects to be included under workers compensation insurance coverage.

This form must be retained by the workers compensationinsurance carrier.