Please Transpose to Company Letterhead

***Transfer to Company Letterhead, Original Signature and Mail to NYSIF***

**THIS IS NOT A REQUEST TO CHANGE REPRESENTATIVES**

Date:

Attn: Broker’s Desk

New York State Insurance Fund

199 Church Street

New York, NY 10007

Fax (607) 741-5005

Policy Number:

To Whom it May Concern:

I hereby authorize Labor Law 240 Insurance RPG Brokers and/or its representative to have complete access to claim file information and detail regarding all losses with the State Insurance Fund.

I would appreciate you forwarding this information directly to Labor Law 240 Insurance RPG Brokers

at the fax/address below.

Labor Law 240 Insurance RPG

33 Loman Court

Cresskill, NJ 07626

Attn: Mark Sherry

Fax Number: (201) 734-6165

E-Mail:

Thank you in advance for your anticipated prompt attention to this matter.

Very truly yours,

______

(Print Name)

______

(Signature)

______

(Title)