ACORD 174NY Instructions

ACORD 174 NY (7/96) – New York Revocation of an Incorporated Religious, Charitable, Educational or U.S. War Veterans Organizationto 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 revoke previous election to be included under workers compensation insurance coverage.

This form must be sent to the Chair, New York Workers Compensation Board. A copy must be retained by the workers compensation insurance carrier. Copies should also be sent to each executive officer named in the form.