N.Y. Comp. Codes R. & Regs. tit. 12, § 358-3.4 – Procedure for obtaining acceptance of plans under subdivisions 4 and 5 of section 211 of the Workers' Compensation Law.

(a) a statement setting forth the provisions of the plan and, if required by the chairman, a copy of the plan;
(b) a written agreement with the chairman, providing that the employer, or in his behalf the carrier, will pay all assessments to the special fund under section 214 of the Workers' Compensation Law and all assessments for expenses of administration under section 228;
(c) a written agreement, satisfactory to the chairman, if the plan is one that under subdivision (b) of section 358-1.1, subdivision (b) of section 358-1.2 or section 358-2.1 requires such agreement, that the benefits under the plan will be continued with respect to all employees included under the plan for disabilities occurring prior to the date the employer files with the chairman written notice of termination of the plan;
(d) evidence satisfactory to the chairman that the obligation to pay benefits under the plan has been insured and is kept insured, either with a stock or mutual corporation or reciprocal insurer duly authorized to transact the business of accident and health insurance in this State, or with the State Fund, or proof satisfactory to the chairman of financial ability to pay such benefits and otherwise complying with subdivision 3 of section 211.
Such application shall be duly verified before a notary public.

An employer who has an existing plan or a new plan, and who desires to be permitted to provide benefits thereunder in lieu of the statutory benefits for a class or classes of employees, may apply in writing to the chairman to have the plan accepted. The employer shall, as a part of such application, and in form prescribed by the chairman, file with the chairman: