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Untitled (1 ," '- (' ) tA.~"rV :.'.i.L"llil G' S TATE & M ICIPAL AGENCY COMPLIANCE. WITH 57 WCL November 3, 2003 STATE & MUNICIPAL AGENCY COMPLIANCE WITH 957 WCL Table of Contents Overview of Section 57 and Workers' Compensation Insurance Coverage Requirements... ........................................... .................................................................... Page 1 How to request Compliance forms...................................................................................................... ............ Page 1 Chairman's Announcement - Fonn WCIDB-IOO and Fonn WCIDB-IOI Together Replace the C-I05.21 Fonn...Page 2 Sample Form WCIDB-I 00 -- Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required.............. ...... .................. ............. .............. .............. .Page 3 Sample Form WC/DB-lOl-- ,.x ..... ..................................................... Page 5 Sample C-105.2 Form -- Certificate of New York State Workers' Compensation Insurance.................Page 7 Sample U-26.3 Form -- State Insurance Fund version of New York State Certificate of Workers' Compensation Insurance.................. ................. ........................................... Page 9 Sample SI-12 Form -- Certificate of Workers' Compensation Self-Insurance ..................................Page 10 Sample OSI-I05.2 Form -- Certificate of Workers' Compensation Group Self-Insurance .......................Page 11 Liabilities and Penalties for Noncompliance. ..... ................................................................. ........................... .Page 12 Section 57 -- Restriction on Issue of Permits and the Entering of Contracts Unless Compensation Is Secured Section 57 of the Workers' Compensation Law (WCL) requires the heads of all State and municipal entities, priorto issuing any permits, licenses or entering into contracts, to ensure that businesses applying for those permits, licenses or entering into contracts have appropriate workers' compensation insurance coverage. To comply with coverage provisions of the Workers' Compensation Law, businesses must: A) be legally exempt from obtaining workers' compensation insurance coverage. B) obtain such coverage from insurance carriers; or C) be self-insured. To assist State and municipal entities in enforcing Section 57 of the Workers' Compensation Law, businesses requesting permits, licenses or seeking to enter into contracts must provide ONE of the following forms to the entity issuing the permit, license or entering into a contract: A) WC/DB-l 00, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Worker~.'Com ensation And/Or Disability Benefits Insurance Coverage I~.1'J~t Required; OR WC/DB-lOl, ~.aavi :'''l'-:-';''~:<'TJi '-':-'-~ew!York .~.::;:/~t'4....~-' :;;O;:iP:!;"::..;. :,' ,c., ",~l<\:~',<:,:"::,:;>,~'t,>;;;;.,:-'" ,'. ',., _:"u_', ..e.....0uil"eS . Ie "::Benents }:r___. ,,- ~'_""_'" """_".",.",,""'_. ~; (Affidavits must be stamped as received by the NYS Workers' Compensation Board); OR B) C-l 05.2 -- Certificate of Workers' Compensation Insurance (the business' insurance carrier will send this form to the government entity upon the business' request) PLEASE NOTE: The State Insurance Fund provides its own version of this form, the U-26.3; OR C) SI -12 -- Certificate ofW orkers' Compensation Self-Insurance or GSI -105.2 -- Certificate of Group Workers' Compensation Self-Insurance (please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!) Government Officials Local Contacts with the NYS Workers' Compensation Board Government Officials should call the Workers' Compensation Board's Enforcement Unit in the nearest district office to notify them of a business in noncompliance: Albany (518) 486-3349 Manhattan (212) 932-7576 Binghamton (607) 721-8334 Peekskill (914) 788-5804 Brooklyn (718) 802-6870 Queens (718) 523-8409 Buffalo (716) 842-2057 Rochester (585) 238-8335 Hauppauge (631) 952-6698 Syracuse (315) 423-1141 Hempstead (516) 560-7742 How a Business Requests a SI-12 Form or a GSI-I05.2 Form Businesses should call the Workers' Compensation Board's Self-Insurance Office to obtain a SI-12 -- Certificate of Workers' Compensation Self-Insurance at (518) 402-0247 or contact their Group Self-Insurance Administrator for a copy ofthe GSI-I05.2 -- Certificate of Group Workers' Compensation Self-Insurance. Please call the Bureau of Compliance at (518) 486-6307 with any general questions regarding Section 57 of the Workers' Compensation Law. -1- Subject No. 046-122 STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY, NY 12207 www.wcb.state.ny.us THIS AGENCY EMPLOYS AND SERVE PEOPLE WITH DISABILITIES WITHOU' DISCRIMINATION. JEFFREY R. SWEET ACTING CHAIRMAN CHAIRMAN'S ANNOUNCEMENT NEW FORMS WC/DB-100 AND WC/DB-101 Date: November 3, 2003 Effective December 1,2003, the following new forms are to be used in place of Form C-105.21, Statement that a Business Does Not Require WC or DB Coverage: . WC/DB-100, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required . WC/DB-1 01, Affidavit That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State Does Not Require Specific New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage These affidavit forms can ONLY be used to attest to a aovernment entity that the applicant requesting a permit, license or contract from that government entity is not required to carry workers' compensation and/or disability benefits insurance. IMPORTANT: These forms cannot be used to waive the workers' compensation rights or obligations of any party including a subcontractor.' The applicant requesting a permit, license or contract from a government entity must complete the appropriate form, have it notarized, and then mail or fax it to nearest district office of the Workers' Compensation Board. At the Board, the form will be reviewed for completeness and, if completed properly, it will be stamped as received and returned by fax or mail to the sender. The affidavits are valid for one year from the date of receipt by the Workers' Compensation Board. Although the Board does not sign or approve the affidavits, it may investigate entities claiming exemption from the coverage requirements of the Law. Any false statement, representation or concealment will subject business owners to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws. New forms WC/DB-100 and WC/DB-101 are available on the Board's website, www.wcb.state.nv.us. under the heading "Common Forms Online." They may also be obtained by writing or visiting any District Office of the Workers' Compensation Board. Because new forms WCIDB-100 and WC/DB-101 are sworn affidavits, employees of the Workers' Compensation Board cannot assist applicants in answering questions about these forms. Please contact an attorney if you have any questions regarding either the WC/DB-100 form or WC/DB-101 form. Jeffrey R. Sweet Acting Chairman -2- NYS WCB NYS WCB NYS WCB NYS WCB NYS WCB WCIOB100/101 NYS WCB NYS WCB NYS WCB WCIOB100/101 WCIOB100/101 WCIOBl 00/1 01 WCIOB1001101 107 WCIOB1001101 NYS WCB woos 1 00/1 01 WCIOB100J101 168-'16 91st NYS WCB 100 Broadway State Office 111 Livingston Delaware 220 Rabro WCIOBl 00/1 01 215 W. 125th 41 North Ave. WCIOB100/101 NYS WCB Menands Building SI. Ave. Drive 175 Fulton SI. Division 5t. 3rd Floor 130 Main SI. WCIOB100/101 ALBANY 44 Hawley Street 22nd Floor BUFFALO Su~e 100 Ave. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 James SI. 12241 BINGHAMTON BROOKLYN 14202 HAUPPAUGE HEMPSTEAD NEW YORK 10566 11432 14614 SYRACUSE (866) 750- 13901 11201 (866)211- 11788 11550 10027 (866) 746- (800) 877- (866)211- 13203 5157 (866) 802-3604 (800) 877-1373 0645 (866) 681-5354 (866) 805-3630 (800) 877-1373 0552 1373 0644 (866) 802-3730 FaX# (518) Fax# (607) Fad (718) Fad (716) Fad (631) FaX# (516) FaX# (212) Fad (914) FaX# (718) FaX# (585) FaX# (315) 423- 473-9166 721-8324 802-6642 842-2132 952-7966 560-7807 316-9183 788-5793 291-7248 238-8351 2938 Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation Arid/Or Disability Benefits Insurance Coverage Is Not Required (Incomplete forms will be returned - Please contact an attorney if you have any questions regarding this form.) **Tltis/orm cannot be used to waive the workers' compensation rigltts or obligations of all)' party including a subcollfractor** The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers' compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at the fax number or address listed on the top of this form. Incomplete forms will be returned. Please note: This statement must be notarized and also have been stamped by the New York State Workers' Compensation Board. This affidavit will not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WCIDB 100 form, the Workers' Compensation Board will stamp this form as received and return it to you by either mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which you are requesting a permit, license or contract. In the Application of (Business Name and Address) for a permit/license/contract County of ) ) ss.: ) State of (applicant's name) being duly sworn, deposes and says: (position) with (business or trade (type o/business). The telephone number of the business is L-) Employer Identification Number of the business (or the Social Security Number of the business owner) is The New York State Unemployment Insurance Employer Registration Number (if any) of the business is that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address is and my home telephone <--J 3. That the above named business is applying for a applying/or) from 3a) (Optional name), a The Federal l. am the I affirm number is (type of permit/ license/contract (governmental entity issuing the permit/ license/contract). will be performed in New York State from to (dates necessary to complete work associated with permit/license/contract). The estimated dollar amount of project is . } 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from 4a. through 4h.): o 4a.) the business is owned by one individual and is not a corporation. Other than the owner, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). o 4b.) the business is a partnership under the laws of New York State and is not a corporation. Other than the partners, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). (Must attach separate sheet with a list of all the partners names and also with the signatures of all the partners.) o 4c.) the business is a one person owned corporation, with that individual owning all of the stock and holding all offices of the corporation Other than the corporate owner, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). Location of where work WCIDB 100 (12/03) {Replaces C-105.21 Form} -3- (Over) Ll 4d.) the business is a two person owned corporation, with those individuals owning all of the stock and holding ,all offic,es of the corporation (each individual must own at least one share of stock). Other than the corporate owners, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). (Must attacll separate sheet with a list o/the names o/both owners, and also with both owners' signatures.) Ll 4e.) the applicant is a nonprofit entity (under IRS rules). With the exception of clergy or teachers, the nonprofit has no compensated individuals or subcontractors providing any services. Ll 4f.) the business is a farm with less than $1,200 in payroll the preceding calendar year. Ll 4g.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. Only uncompensated friends/family are helping to build this structure. Ll 4h.) other than the business owner(s) and individuals obtained from a registered temporary service agency, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). Other than the business owner(s), all individuals providing services to the business are obtained from a registered temporary service agency and that agency has covered these individuals for New York State workers' compensation insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation 5. That the above named business is certifying that it is exempt from obtaining New York State disability benefits insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from Sa. through Sf.): Ll Sa.) the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation. In addition, the business does not require disability benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability Benefits Law.) Ll Sb.) the applicant is a political subdivision that is legally exempt from providing statutory disability benefits coverage. Ll Sc.) the applicant is a nonprofit religious, charitable or educational institution. With the exception of executive officers, clergy, sextons, teachers or professionals, the nonprofit has no compensated individuals providing services. LlSd.) the business is a farm and all employees are farm laborers. Ll Se.) the applicant is a homeowner serving as the general contractor for hislher primary/secondary personal residence. Onlv uncompensated friends/family are helping to build this structure. Ll Sf.) other than the business owner(s) and individuals obtained from the temporary service agency, there are no other employees. Other than the business owner(s), all individuals providing services to the business are obtained from a registered temporary service agency and that agency has covered these individuals for New York State disability benefits insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation. 6. That if circumstances change so that workers' compensation insurance and/or disability benefits coverage is required, such as the hiring of employees, the above-named business will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers' Compensation Board to the government entity listed in item 3 on the front of this form. 7. That based on the facts presented, I certify that the above-named business does not require (check box 7a. and/or 7b.): Ll7a.) workers' compensation insurance. (applicant must have checked ONE of the boxes from 4a. through 4h.) Ll 7b.) disability benefits insurance. (applicant must have checked ONE of the boxes from Sa. through Sf.) 8. By signing my name below, I hereby affirm that the statements made herein are true, that I have not made any materially false statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that any false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws. (Applicant's Signature --first and last name) Sworn to before me this Day of ,20_ Notary Public NYS Workers' Compensation Board Received Stamp Because this is a sworn affidavit, employees ofthe Workers' Compensation Board cannot assist applicants in answering questions about this form. WC/DB 100 (12/03) {Replaces C-105.21 Form} -4- (Over) NYS WCB NYS WCB NYS WCB NYS WCB NYS WCB WClDB1 00/1 01 NYS WCB NYS WCB NYS WCB WClDB1001101 WCI081001101 WClDB1001101 WClDBloo/101 107 WClDBl001101 NYS WCB WCIOB 1 00/1 01 WClDB1001101 168-46 91st NYS WCB 100 Broadway State Office 111 Livingston Delaware 220 Rabro WClDBl001101 215 W. 125th 41 North Ave. WCIDB100/101 NYS WeB Menands Building SI. Ave. Drive 175 Fulton SI. Division Sf. 3rd Floor 130 Main St WClDB 1 00/1 01 ALBANY 44 Hawley Street 22nd Floor BUFFALO Suite 100 Ave. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 James SI. 12241 BINGHAMTON BROOKLYN 14202 HAUPPAUGE HEMPSTEAD NEW YORK 10566 11432 14614 SYRACUSE (866) 750- 13901 11201 (866)211- 11788 11550 10027 (866) 748- (800) 877- (866)211- 13203 5157 (866) 802-3604 (800) 877-1373 0645 (866) 681-5354 (866) 805-3630 (800) 877-1373 0552 1373 0644 (866) 802-3730 Fax# (518) Fax# (607) Fax# (718) FaxJI (716) Fax# (631) FaX# (516) FaxJI (212) Fax# (914) Fax# (718) Fax# (5B5) Fax# (315) 423- 473-9166 72 Hl324 802-6642 842-2132 952-7966 560-7807 316-9183 788-5793 291-7248 238-8351 2938 (Incomplete forms will be returned - Please contact an attorney if you have any questions regarding this fornL) **Tltis form cannot be used to waive tile workers' compensation rigltts or obligations of any party including a subcontractor** The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers' compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at the fax number or address listed on the top of this form. Incomplete forms will be returned. Please note: This statement must be notarized and also have been stamped by the New York State Workers' Compensation Board. This affidavit will not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WCIDB-IOI form, the Workers' Compensation Board will stamp this form as received and return it to you by either mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which you are requesting a permit, license or contract. In the Application of (Business Name and Address) permit/license/contract fora State of County of ) ) sS.: ) (applicant's name) being duly sworn, deposes and says: 1. I am the (position) with (business or trade name), a (type of business). The telephone number of the business is L-J The Federal Employer Identification Number of the business (or the Social Security Number of the business owner) is The New York State Unemployment Insurance Employer Registration Number (if any) of the business is . I affirm that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address IS number is L-) and my home telephone 3. That the above named business is applying for a applyingfor) from 3a) {Optional Location of where work (type of perm it/ licenselcontract (governmental entity issuing the perm it/ licenselcontract). will be performed in New York State from to __ (dates estimated dollar amount of project is necessary to complete .j 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check either box 4a or 4b): work associated with permit/license/contract). The WC/DB-101 (12/03) {Replaces C-105.21 Form} -5- (Over) o 4a) the business is from outside of New York State, and wishes to use its foreign or other state's workers' compensation insurance policy to cover its employees while they are working in New York State. To check this box, the applicant ~ have New York (NY) specifically listed on Item 3C on the Information Page of its workers' compensation insurance policy (Exception-3C coverage not required for contracts where ALL work is done outside of New York State), and M1ISI. attach a certificate of insurance from its foreign or other State's workers' compensation insurance policy to this Affidavit (and listed the governmental entity issuing the permit! license/contract as the Certificate Holder). Further, by checking box "4a" on this form, the applicant CERTIFIES thatfor the period covered by this exemption form the above business DOES NOT or WILL NOT meet any of the following four criteria (400. - 4ad.). 4aa. has a physical location within New York State, nor 4ab. has more than $50,000 in labor costs in a calendar year for employees and subcontractors working in New York State, ntOr 4ac. has one or more employees (including subcontractors) with a primary work location or hired within New York State, nor 4ad. has an employee or employees (including subcontractors) working in New York State more than 90 days in a calendar year. Applicants that meet any of the above four criteria (4aa. - 4ad.), CANNOT check "box 4a" on this form and CANNOT file this form for a workers' compensation exemption. PLEASE NOTE: Applicants that meet any of the above four criteria (4aa. - 4ad.), are REQUIRED to have a full New York State workers' compensation policy (NY listed under Item 3A on the Information Page of the insurance policy) and mustflle either a C-I05.2 - Certificate of Workers' Compe1lsatio1l 11lsura1lce OR a U-26.3, the State Insurance Fund's version of this form (the busi1less' i1lsurance carrier will se1ld theseforms to the govemment e1ltity issuing the permit, license or contract upon the business' request) as proof of this coverage. [Applicants that DO NOT meet al'Y of the above four criteria (4aa. - 4ad.) are NOT required to have NY listed under Item 3A on the Information Page of the insurance policy. Instead, the out-of-state employer's employees will be covered when working in New York by having NY listed in Item iC on the Information Page of the workers' compe1lsation insurance policy (the other-states section).} o 4b) All employees from the entity applying for the permit, license or contract are direct employees ofa government entity outside of New York State and such employees are outside the jurisdiction of New York State workers' compensation coverage. (Applicant MIl.SI attach a certificate of insurance from its foreign or other State's workers' compensation insurance policy to this Affidavit) 5. That the above named business is certifying that it is exempt from obtaining New York State disability benefits insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE ofthe boxes from 5a. through 5b.): o 5a.) the business does not require disability benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability Benefits Law.) . o 5b.) All employees from the entity applying for the permit, license or contract are direct employees of a government entity outside of New York State and such employees are outside the jurisdiction of New York disability benefits coverage. 6. That if circumstances change so that workers' compensation insurance and/or disability benefits coverage is required, the above- named business will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers' Compensation Board to the government entity listed in item 3 on the front of this form. 7. That based on the facts presented, I certify that the above-named business does not require (check box 7a. and/or 7b.): o 7a.) workers' compensation insurance. (applicant must' have checked box 4a or 4b and attached a certificate of insurance from its foreign or other State's workers' compensation insurance policy to this Affidavit) o 7b.) disability benefits insurance. (applicant must have checked either box 5a.or 5b.) 8. By signing my name below, I hereby affirm that the statements made herein are true, that I have not made any materially false statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that any false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws. (Applicant's Signature --first and last name) Sworn to before me this Day of ,20_ Notary Public Because this is a sworn affidavit, employees of the Workers' Compensation Board cannot assist applicants in answering questions about this form. WC/DB-101 (12/03) {Replaces C-I05.21 Form} -6- (Over) STATE OF NEW YORK WORKERS' COMPENSA nON BOARD CERTIFICA TE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and address ofInsured (Use street address only) I b. Business Telephone Number of Insured I c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (On/y required if coverage is specifically limited /0 cer/ain/oca/ions in New York State, i.e. a Wrap-Up Policy) I~ 6';"~" I d. Federal Employer Ident~.9cation 1\rumber of Insured or Social Security Nu er 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) 3a. .;to ners or Executive. Officers are: (Definitioli of Demolition on Reverse) bove " insures the business referenced above in box "Ia" for workers' ensation La . (To use this form, New York (NY) must be listed under N PAGE of th or rs' compensation insurance policy). The Insurance Carrier or its surance to the It)' listed above as the certificate holder in box "2". holder within J 0 days IF a policy is canceled due to nonpayment of premiums rpayment of premiums that cancel the policy or eliminate the insured from the (These noti s may be sent by regular mail.) Otherwise, this Certificate is validfor a maximum of the insurance carrier or its licensed agent. or rs' compensation policy indicated on this form, ifthe business continues to be named on a permit, older, the business must provide that certificate holder with a new Certificate of Workers' d proof that the business is complying with the mandatory coverage requirements ofthe New York ify that I am an authorized representative or licensed agent of the insurance carrier referenced red has the coverage as depicted on this form. (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signature) (Date) Title: Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-J05.2 form. authorized to issue it. C-I05.2 (12-03) Insurance brokers are NOT -7- Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. I. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employinent of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees hasj;)~~vecured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such stal r murricipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or reqUIre to en " '1<1ny c~ntract for or in connection with any work involving the employment of employees in a hazardous employment defin IS 'chapter, n4lt~hstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such cont a ss proof dulfubscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensat' n for all employees ha A provided by this chapter. Definition of Demolition (Box "3e." on the reverse side of this form) A building wrecking or demolition is one where a building, chimneX,Qr '" 'h" ed, or ".' ,;~ floor, er.::. lOr wall or roof is removed. ~,,?:O" ""1i:i::'''' 't"f'~1'~~ ","",.><,' If the contract involves only the removal of interior walls, partitio <, 'i' the facingio,ri!r of any exie;. ~~tit is not considered demolition. f-state employer meets an fthe above criteria, it is required to carry a New York State workers' compensation policy. When 's listed i tern. on the ation Page of an employer's workers' compensation insurance policy, the employer is fully , Com sation Law. Ifinsured through a private insurance carrier, the out-of-state employer must file a Co pensation Insurance (the business' insurance carrier will send this fonn to the government entity e New York State Insurance Fund provides its own version of this form, the U-26.3. If the out-of-state fully sel ured in New York State, the out-of-state employer must file a SI-12 - Certificate of Workers' the business calls the Board's Self-Insurance Office at 518-402-0247). If the out-of-state employer is participating in group f-insurance, the out-of-state employer must file a GSI-I05.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance (the business' Group Self- Insurance Administrator will send this form to the goyernmemt entity upon request). Out-of-State Companies Working in NYS -- NYS W r' Licenses or Contracts issued by NYS Government En nd Disability Benefits Requirements for Permits, olicies that cover each state in which they employ ou are PtP ably aware, certain insurance carriers write policies ation Page of the policy specify the states of coverage. In e policy. out-of-state employer needs to be specifically covered for NYS cient conta s" between that employer and the state. While there is no single the asis for fmding "sufficient contacts" requiring New York coverage: If an out-of-state employer does not meet any of the above criteria and has New York (NY) listed in Item 3C on the Information Page ofits workers' compensation insurance policy (the Other States Insurance section), NYS specific coverage is not required and the employer may be able to use its own state's workers' compensation coverage by filing a WC/DB-lO I form. [The out-of-state employer's employees will be covered under NY benefits when working in New York by having NY listed in Item 3C on the Information Page of tIle workers' compensation insurance policy (the Other States Insurance section).] -8- C-I05.2 (12-03) Reverse ~ 1 ... "" Y)' 1 V J ~ '-' \Ul \,.. 11 ....:l\..u ~. .......... . ~ I . '-A _ Jforl..a.s CompCnmlion &: DL~abifil)' &ne.fits Sp/,!cialisr!l Since /914 199 CHURCH STREET. NEW YORK. N.Y. 10007-1100 Phone: (212) 587-3976 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE THIS POLlC jPOLlCYHOLDER- l_ _______ __ . I POLICY-NUMBER""" 1 CERTIFICATE NUMBER L __ _.___ __-1 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED FUND UNDER POLICY NO. 1195 111-8 UNTIL 04/16/20 FOR WORKERS' COMPENSATION UNDER THE N OPERATIONS IN THE STATE OF NEW YORK, EX PERIOD IN SUCH MANNER AS TO AFFECT THIS LATIO ILL BE GIVEN TO THE CERTIFICATE HOLDER SUFFICIENT COMPLIANCE WITH THIS PROVISION. ME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE THIS CERTIFICATE DOES R 0 NFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE R. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE NEW YORK STATE INSURANCE FUN[ t1~~ DIRECTOR, INSURANCE FUND UNDERWRITING This certificate can be validated on our web site alhllps://www.nysiLcom/certlcertval.asp .26.3 VALIDATION NUMBER: 371850811\ -9- .. STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY. NY 12207 THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. JEFFREY R. SWEET ACTING CHAIRMAN Office of the Secretary I, , Secretary to the Workers' Compensation Board 0 / DO HEREBY CERTIFY, that to its employees as a self-insurer in the following manner: Pursuant to Section 50, subdivisions 3 (County, city, village, town, schoo 1st '~:'~ dJ}~; opensation Law. olitical subdivision) Pursuant to Article 5 of the Wor and such status still remains in full force. WITNESS WHEREOF, I have hereunto set d and affixed the seal of the Workers' Compensation 20_ by...................................... ............. Secretary to the Board 81-12 (10-03) -10- STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION GROUP SELF-INSURANCE la. Legal Name and Address of Business Participating 'in 'Croup Self-Insurance (Use Street Address Only) Id. Business Tele hone Number of Business referenced in box "la" Ie. NYS Unemployment Insurance Employer Registration Number of Business referenced in box "!a" lb. Effective Date of Membership in the Group Ic. The Proprietor, Partners or Executive Officers are o included (only check box if all partners/officers included) o all excluded or certain partners/officers excluded ess referenced in 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as Certificate Holder) with the mandatory coverage requirements of the em r of the Group Self-Insurer listed above in box "3" Group Self-Insurer's Administrator will send this Certificate holder in box "2". e certificate holder within 10 days IF the membership of the If this certificate is to the above guidelines and the business referenced in box "]a" continues to be named on a permit, lice or contra 'ssued by the certificate holder, the business must provide the certificate holder either with a new certificate or other author d proof the business is complying with the mandatory coverage requirements of the New York State Workers' Co on Law. Under penalty of perjury, I rtify that I am an authorized representative of the Group Self-Insurer referenced above and that the business referenced in box "la" has the coverage as depicted on this form. Certified by: (Print name of authorized representative of the Group Self-Insurer) Certified by: (Signature) (Date) Title: Telephone Nwnber: OSI-l05.2 (2-02) -11- LIABILITY AND PENALTIES FOR VIOLATIONS OF MANDATORY. WORKERS' COMPENSATION INSURANCE COVERAGE REQUIREMENTS Ascertaining Violations of the Law The Workers' Compensation Board may require an employer to furnish proof that the employer: has a valid workers' compensation insurance policy; is self-insured for workers' compensation; or is legally exempt from having to obtain workers' compensation coverage. If an employer fails to provide this information within 10 days following the Board's request, the Board assumes that the employer is violating the Workers' Compensation Law (WCL). Personal Accountability The sole proprietor or the partners of a business, or the President, Secretary and Treasurer of a corporation are personally liable for the business' failure to secure workers' compensation insurance. Liability for Claims Incurred by an Uninsured Employer -- Section 26-a of the WCL The employer is liable for paying an assessment of $250 for each claim incurred while uninsured plus 15% of the amount awarded (minimum of $1,500--maximum of $5,000) plus the actual award (including both compensation and medical costs) plus any penalties the Board assesses for noncompliance. In cases involving severely injured employees, the medical costs alone could be in the hundreds of thousands of dollars per injury!!! Penalties for Noncompliance 1) Section 52-5 of the WCL -- The Board may impose upon an employer, in addition to all other penalties, a fine of $250 for each to-day period of noncompliance or 2 percent of the employer's payroll during the period of noncompliance. The fine of $250 for each 1 O-day period of noncompliance is the most commonly imposed penalty for noncompliance. 2) Section 52-1 of the WCL -- Not securing workers' compensation insurance is a misdemeanor -- punishable by a fine of not less than $500 nor more than $2,500 or imprisonment for up to one year. A second violation of the Law within five years may result in a fine of not less than $1,000 nor more than $5,000. A third or subsequent violation of the Law within five years may result in a fme of up to $7,500. The Board enforces these penalties against employers for blatant cases of abuse and levies them in addition to penalties contained in paragraph "1", and liabilities and penalties incurred for claims incurred while uninsured. Additional Liability for Uninsured Employers 1) An uninsured employer is responsible for obtaining and paying for any legal representation required to defend against a workers' compensation claim. (An insured employer's workers' compensation insurance carrier provides such representation as part of the workers' compensation insurance policy's coverage.) 2) An uninsured employer can be directly sued by an injured employee. (In most cases, an employer's workers' compensation insurance is the sole recourse for the employer's injured employees.) -12- STATE & M ICIPAL AGENCY COMPLIANCE WITH 125 General Municipal Law November 3, 2003 STATE & MUNICIPAL AGENCY COMPLIANCE WITH S125 GENERAL MUNICIPAL LAW Table of Contents Overview of Section 125 General Municipal Law Insurance Coverage Requi.rements... ...................... ............. .............. ... .................. .................... ................ Page 1 Sample BP-I Form -- Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1,2,3 or 4 Family, Owner-occupied Residence ..............Page 3 STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY, NY 12207 nilS AGENCY EMPlOYS AND SERVES PEOPlE WITH DISABIlITIES WITHOUT DISCRIMtNA TION. ROBERT R. SNASHALL CHAIRMAN June I, 1999 To all Code Enforcement Officials, Building Departments and Municipal Entities: Effective January 18, 1999, Section 125 afthe General Municipal Law requires that any individual applying far a building permit must prove to. the building department that he/she is in campliance with the mandatory coverage provisians of the Warkers' Co.mpensation Law before the building permit is issued. General Background Under Sectian 57 afthe Warkers' Campensation Law, businesses listed as the general contractars an building permits are required to. submit proof of compliance with the mandatory coverage provisians o.fthe Workers' Campensatian Law to. the building department before a building permit is issued. Sectian 125 o.fthe General Municipal Law is specifically targeted at ensuring that aU applicants who. list themselves as the general contractors an the building permit are in compliance with the mandatory coverage pravisions afthe Warkers' Co.mpensatian Law. Fo.rhameowner applicants, enclased is a copy afthe new farm BP-I (3199) Affidavit of Exemption to. Show Specific Proof of Workers' Compensation Insurance Coverage far a 1,2,3 or 4 Family, Owner-i>ccupied Residence. The law requires ho.meowners to. pravide proof of workers' compensatio.n compliance when applying fo.r a building permit Hthe homeowner qualifies for an exemption, the ho.meowner must complete this farm and file it with the local building department. Implementing Section 125 af the General Municipal ~w 1. General Contractars and Business Owners Businesses listed as the gen~raI contractors an building permits, must prove that they are in compliance with Sectian 57 of the Workers' COmpensatio.n Law (WCL) by producing ONE of the following farms indicating that they are: + insured (C-I 05.2 ar U-263 - the business' insurance carrier will send this form to. the building dep3rtment upon the business' request), + self-insured (81-12 -:- the business calls the Baard's Self-Insurance Office at (518) 402-0247 ar + are exempt (C-I05.21 - farms obtained from Workers' Compensatian Bo.ard affices - copy attached), under the mandatory coverage provisians of the WCL. Any residence that is not a 1,1,3 ar 4 Family, Owner-occupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. (please note: ACORD forms are rIQI acceptable proof aCworkers' compensation coverage!) 2. Owner-occupied Residences Ho.meowners afa 1,2,3 or 4 Family, Owner-i>ccupied Residence, must file farm BP-I(3/99) when applying far a building permit when they are: .... listed as the general contractor on the building permit, and the homeowner: ~ is perfo.rming all the work forwhich the building permit was issued him/herself, ~ is DOt hiring. paying or compensating in any way, the individual(s) that is(are) perfonning all the work for \\!Ilich the building penn it was issued or helping the homeowner perform such worle, or -1- . '. ~ . has a homCowner~s insurance policy that is cu~ntly in cft'ec:t and Covers the propertY forwhkh tho building pennitwas issued AND the homeowner is hiring or paying individuals a total ofless than 40 hours perwcek (aggregate hours for all paid individuals on the jobsite) for the work for which the buildmg penn it was issued. . ... If the homeowner of a 1,2,3 or 4 Family, Owner-occupied Residence is hiring or paying individuals a total of 40 hours or MORE in any week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeowner may not file the "Affidavit of Exemption" form, BP-l(3/99), but must either: ~ acquire appropriate workers' compensation coverage and provide, to the government entity issuing the building permit, appropriate proof of that coverage, on forms C-I 05.2 or U-26.3, OR ~ have the general contractor performing the work provide appropriate proof of workers' compensation coverage, or proof of exemption from that coverage, to the government entity issuing the building penn it. Background on Coordinating the Implementation of Section 125 of the General Municipal Law with Existing Statutes To ensure that homeowners are not required to have duplicate workers' compensation coverage, the implementation fonn attempts to coordinate compliance with Section 125 of the Municipal Law with coverage provided under Section 34200) of the Insurance Law, which is the homeowner's policy's workers' compensation insurance rider. . As of March I, 1985, the New York State Insurance Law ~ 3420(j) provides that every policy of comprehensive personal liability insurance (i.e., homeowner's insurance) on a 1,2,3 or 4 family owner-occupied dwelling (including condominiums) will also provid~ workers' compensation benefits. This section was added to protect the homeowner from unexpected liability . when the Board determines that a person, whom the homeowner did not believe required coverage, is found to be entitled to benefits. To receive benefits under this policy, the employee must be found by the Board to have been injured in employment of the policyholder and employed for less than 40 hours a week in and about the owner's 1, 2, 3 or 4 family resiidence in this State. . The BP-I form reflects the minimum standard to be applied statewide. if a municipality wishes to collect a copy of the certificate of insurance from a building permit applicant'shomeowner's insurance policy or obtain a copy ofth~ information page from the building penuit applicant's homeowner's insurance policy, the municipality could make that a local requirement which would be in addition to the State requirement. . Please make as many copies of the enclosed BP- I (3/99) and the C- I 05.21 (8/98) as you require. If you have 4I1Y questions regarding the BP-I fonn, Section 125 of the General Municipal Law or Section 57 of the Workers' Compensation Law, please c:on~~ Steve Carbone of the NYS Workers' Compensation Board at 518-486-6307. Thank you for your office's cooperation in enforcing Section 125 of the General Municipal Law and Section 57 of the Workers' Compensation Law. Sincerely, /Jt3;;(!;t&- K. Brian Collins Director, Bureau of Compliance -2- Affidavit of Exemption to Show Specific Proof ofWorkers~, Compensation Insurance Coverage for a 1,2, 3 or 4 Family, Owner-occupied Residence Under penalty of perjury, I certify that I am the owner of the 1,2,3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the appropriate box): o I am performing all the work for which the building permit was issued. o I am not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work for which the building permit was issued or helping me perform such work. o I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: .. acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit ifl need to hire or pay individuals a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit; OR .. have the general contractor, performing the work on the I, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, provide appropriate proof of workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit. (Signature of Homeowner) (Date Signed) Home Telephone Number (Homeowner's Name Printed) Sworn to before me this day of ~. , Property Address that requires the building permit: (County Clerk or Notary Public) BP-I (3/99) -. - -3- _......v""... .1"~". ..-......., ."''''" CHAPTER 439 The general municipal law is amended by adding a new section 125 to read as follows: g ]25. ISSUANCE OF BUILDING PERMITS. NO CITY, TOWN OR VILLAGE SHALL ISSUE A BUILDING PERMIT WITHOUT OBTAINING FROM THE PERMIT APPLICANT EITHER: ]. PROOF DULY SUBSCRIBED THAT WORKERS' COMPENSATION INSURANCE AND DISABILITY BENEFITS COVERAGE ISSUED BY AN INSURANCE CARRIER IN A FORM SATISFACTORY TO THE CHAIR OF THE WORKERS' COMPENSA TION BOARD AS PROVIDED FOR IN SECTION FIFTY -SEVEN OF THE WORKERS' COMPENSATION LA W IS EFFECTIVE; OR 2. AN AFFIDA VIT THA T SUCH PERMIT APPLICANT HAS NOT ENGAGED AN EMPLOYER OR ANY EMPLOYEES AS THOSE TERMS ARE DEFINED IN SECTION TWO OF THE WORKERS' COMPENSATION LAW TO PERFORM WORK RELATING TO SUCH BUILDING PERMIT. Implementing Section 125 of the General Municipal Law 1. General Contractors and Business Owners For businesses listed as the general contractors on building permits, proof that they are in compliance with Section 57 of the Workers' Compensation Law (WCL) is ONE of the following forms that indicate that they are: .. insured (C-105.2 or U-26.3), . .. self-insured (SI-12), or .. are exempt (C-105.21), underthe mandatory coverage provisions ofthe WCL. Any residence that is not a 1,2,3 or 4 Family, Owner.,occupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. 2. Owner-occupied Residences For homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence, proof of their exemption from the mandatory coverage provisions of the Workers' Compensation Law when applying for a building permit is to file form BP-l(3/99). .. Form BP-I (3/99) shall be filed if the homeowner of a 1,2,3 or 4 Family, Owner-occupied Residence is listed as the general contractor on the building permit, and the homeowner: <7 is performing all the work for which the building permit was issued him/herself, <7 is not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work for which the building permit was issued or helping the homeowner perform such work, or <7 has a homeowner's insurance policy that is currently in effect and covers the property for which the building permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued. .. If the homeowner of a 1,2,3 or 4 Family, Owner-occupied Residence is hiring or paying individuals a total of 40 hours or MORE in any week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeowner may not file the "Affidavit of Exemption" form, BP-I (3/~l9), but shall either: <7 acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit (the C-I 05.2 or U-26.3 form), OR <7 have the general contractor, (performing the work on the I, 2, 3 or 4 fam ily, owner-occupitd residence (including condominiums) listed on the building permit) provide appropriate proof of workers' compensation coverage, or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit. BP-I (3/99) Reverse -4- STATE & M ICIPAL AGENCY COMPLIANCE WITH 220 Subd. 8 DBL November 3, 2003 STATE & MUNICIPAL AGENCY COMPLIANCE WITH 9220 WCL Table of Contents Overview of Section 220 and Disability Benefits Insurance Coverage Requirements.......................................Page I How to request Compliance forms........................................................................................................ ............ ..Page I Chairman's Announcement - Form WC/DB-IOO and Form WC/DB-IOI Together Replace the C-105.2l Fonn.......Page 2 Sample Form WC/DB-IOO -- Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required..............................................Page 3 Sample Form WC/DB-IOl Sample DB-l20.I Form -- Certificate of Disability Benefits Insurance..................................................Page 7 Sample DB-820/829 Form -- Certificate/Cancellation oflnsurance....... ..........................................;.......Page 8 Sample DB-155 Form -- Certificate of Disability Benefits Self-Insurance .........................................Page 9 Section 220 Subd. 8 --Restriction on Issue of Permits and the Entering of Contracts Unless Disability Benefits Is Secu~ed Section 220 Subd. 8 of the Disability Benefits Law (DBL) requires the heads of all State and municipal entities, prior to issuing any permits, licenses or entering into contracts, to ensure that businesses applying for those permits, licenses or entering into contracts have appropriate disability benefits insurance coverage. To comply with coverage provisions of the Disability Benefits Law, businesses may: A) be legally exempt from obtaining disability benefits insurance coverage; B) obtain such coverage from insurance carriers; or C) be self-insured. Accordingly, to assist State and municipal entities in enforcing Section 220 Subd. 8 of the Disability Benefits Law, businesses requesting permits or seeking to enter into contracts must provide ONE of the following forms to the entity issuing the permit or entering into a contract: A) WC/DB-l 00, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Com ensation And/Or Disability Benefits Insurance Coverage Is Not Required; OR WC/DB-lOl,~"g dlOr ; (Affidavits must be stamped as received by the NYS Workers' Compensation Board); OR B) Either the DB-120.1 -- Certificate of Disability Benefits Insurance OR the DB-820/829 Certificate/Cancellation ofInsurance (the business' insurance carrier will send one of these forms to the government entity upon request); OR C) DB-155 -- Certificate of Disability Benefits Self-Insurance. Government Officials Local Contacts with the NYS Workers' Compensation Board Government Officials should call the Workers' Compensation Board's Enforcement Unit in the nearest district office to notify them of a business in noncompliance: Albany Binghamton Brooklyn Buffalo Hauppauge Hempstead (518) 486-3349 (607) 721-8334 (718) 802-6870 (716) 842-2057 (631) 952-6698 (516) 560-7742 Manhattan Peekskill Queens Rochester Syracuse (212) 932-7576 (914) 788-5804 (718) 523-8409 (585) 238-8335 (315)423-1141 How a Business Requests a DB-155 Form Businesses should call the Workers' Compensation Board's Self-Insurance Office to obtain a DB-155 form -- Certificate of Disability Benefits Self-Insurance: Self-Insurance Office (518) 402-0247 Please call the Bureau of Compliance at (518) 486-6307 with any general questions regarding Section 220 Subd. 8 of the Disability Benefits Law. -1- Subject No. 046-122 STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY, NY 12207 www.web.state.ny.us THIS AGENCY eMPLOYS AND SERVE PEOPLE WITH DISABILITIES WITHOU DISCRIMINATION. JEFFREY R. SWEET ACTING CHAIRMAN CHAIRMAN'S ANNOUNCEMENT NEW FORMS WCIDB-100 AND WCIDB-101 Date: November 3, 2003 Effective December 1, 2003, the following new forms are to be used in place of Form C-105.21, Statement that a Business Does Not Require WC or DB Coverage: . WC/DB-100, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required · WC/DB-1 01, Affidavit That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State Does Not Require Specific New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage These affidavit forms can ONLY be used to attest to a government entity that the applicant requesting a permit, license or contract from that government entity is not required to carry workers' compensation and/or disability benefits insurance. IMPORT ANT: These forms cannot be used to waive the workers' compensation rights or obligations of any party including a subcontractor. The applicant requesting a permit, license or contract from a government entity must complete the appropriate form, have it notarized, and then mail or fax it to nearest district office of the Workers' Compensation Board. At the Board, the form will be reviewed for completeness and, if completed properly, it will be stamped as received and returned by fax or mail to the sender. The affidavits are valid for one year from the date of receipt by the Workers' Compensation Board. Although the Board does not sign or approve the affidavits, it may investigate entities claiming exemption from the coverage requirements of the Law. Any false statement, representation or concealment will subject business owners to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws. New forms WC/DB-100 and WC/DB-101 are available on the Board's website, www.wcb.state.nv.us. under the heading "Common Forms Online." They may also be obtain$d by writing or visiting any District Office of the Workers' Compensation Board. Because new forms WC/DB-100 and WC/DB-101 are sworn affidavits, employees of the Worklers' Compensation Board cannot assist applicants in answering questions about these forms. Please contact an attorney if you have any questions regarding either the WC/DB-100 form or WCIDB~101 form. Jeffrey R. Sweet Acting Chairman -2- NYS WCB NYS WCB NYS WCB NYS WCB NYS WCB WClDB1001101 NYS WCB NYS WCB NYS WCB WClDB1001101 WClDB1001101 WClDB1001101 WCIOB1001101 107 WClDB1001101 NY:; WCB WClDBl00/101 WClDB1001101 168-46 91s1 NYS WCB 100 Broadway Slale Office 111 Livingston Delaware 220 Rabro WClDB1001101 215 W. 1251h 41 North Ave. WClDB100/101 NYS WCB Menands Building SI. Ave. Drive 175 Fulton SI Division St. 3rd Floor 130 Main SI. WClDBI 00/1 01 ALBANY 44 Hawley Street 2200 Floor BUFFALO Suite 100 Ave. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 James SI. 12241 BINGHAMTON BROOKLYN 14202 HAUPPAUGE HEMPSTEAD NEW YORK 10566 11432 14614 SYRACUSE (866)750- 13901 11201 (866) 211- i1788 11550 10027 (866) 746- (BOO) 877- (866)211- 13203 5157 (866) 802-3604 (BOO) 877-1373 0645 (866) 681-5354 (866) 805-3630 (800) 877-1373 0552 1373 0644 (866) 802-3730 FaJdI (518) FaxII (607) FaxII (718) FaxiI (716) FaxII (631) FaJdI (516) FaJdI (212) Faldl (914) FaxII (718) FaJdI (585) FaxII (315) 423- 473-9166 721-8324 802-6642 842-2132 952-7966 560-7807 316-9183 788-5793 291-7248 238-8351 2938 Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required (Incomplete forms will be returned - Please contact an attorney if you have any questions regarding this form) **This form canllot be used to waive the workers' compensation rights or obligations of all)' party including a subcolltractor** The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers' compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at the fax number or address listed on the top of this form. Incomplete forms will be returned. Please note: This statement must be notarized and also have been stamfJed by the New York State Workers' Compensation Board. This affidavit will not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WCIDS 100 form, the Workers' Compensation Board will stamp this form as received and return it to you by either mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which you are requesting a permit, license or contract. In the Application of (Business Name and Address) for a pennitllicense/contract County of ) ) ss.: ) State of (type of perm it/ license/contract (governmental entity issuing the permit/ license/contract). will be performed in New York State from to (dates necessary to complete work associated with permit/license/contract). The estimated dollar amount of project is .} 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from 4a. through 4h.): D 4a.) the business is owned by one individual and is not a corporation. Other than the owner, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). D 4b.) the business is a partnership under the laws of New York State and is not a corporation. Other than the partners, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). (Must anach separate sheet with a list of all the partners names and also with the signatures of all the partners.) D 4c.) the business is a one person owned corporation, with that individual owning all of the stock and holding all offices of the corporation Other than the corporate owner, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). (applicant's name) being duly sworn, deposes and says: (position) with (business or trade (type of business). The telephone number of the business is L-) Employer Identification Number of the business (or the Social Security Number of the business owner) is The New York State Unemployment Insurance Employer Registration Number (if any) of the business is that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address is and my home telephone L-) 3. That the above named business is applying for a applyingfor) from 3a) (Optional name), a The Federal 1. am the . I affirm number is Location of where work WCIDB 100 (12/03) {Replaces C-105.21 Form} -3- (Over) __ ........J ...... VU..u.".... ... a LWV "''''''VU VWU"U L.,uIjJUr<1L1UIl, WIUI LUU..C IIIUIVIUU<1IS uwnmg <111 UI 11It: SLUI,;l\. <111U nOlOll!lg all ottices of th corporation (each individual must own at least one share of stock). Other than the corporate owners, there are noemploy'ees, lease employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). (Must attac. separate sheet with Q list of the names of both owners, and a/so with both owners' signatures.) LJ 4e.) the applicant is a nonprofit entity (under IRS rules). With the exception of clergy or teachers, the nonprofit has no compenslltel individuals or subcontractors providing any services. LJ 4f.) the business is a farm with less than $1,200 in payroll the preceding calendar year. LJ 4g.) the applicant is a homeowner serving 'as the general contractor for his/her primary/secondary personal residence. Onl' uncompensated friends/family are helping to build this structure. LJ 4h.) other than the business owner(s) and individuals obtained from a registered temporary service agency, there are no employees leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). Othe than the business owner(s), all individuals providing services to the business are obtained from a registered temporary service agenc) and that agency has covered these individuals for New York State workers' compensation insurance. In additioln, the business i: owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a ~ne or two persor owned corporation, with those individuals owning all of the stock and holding all offices of the corporation 5. That the above named business is certifying that it is exempt from obtaining New York State disability benefits insurance coverage fOI the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from Sa. lhrough 5f.): LJ Sa.) the business is owned by one individual or is a partnership under the laws of New York State and is not a corp~ration; or is a onf or two person owned corporation, with those individuals owning all of the stock i!-nd holding all offices of the corpodation. In addition. the business does not require disability benefits coverage at this time since it has not employed one or more individuals 'on at least 3C days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disabilil) Benefits Law.) LJ 5b.) the applicant is a political subdivision that is legally exempt from providing statutory disability benefits coverage. LJ 5c.) the applicant is a nonprofit religious, charitable or educational institution. With the exception of executive officers, clergy, sextons, teachers or professionals, the nonprofit has no compensated individuals providing services. LJ 5d.) the business is a farm and all employees are farm laborers. LJ 5e.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. Onlv uncompensated friends/family are helping to build this structure. LJ Sf.) other than the business owner(s) and individuals obtained from the temporary service agency, there are no other employees. Other than the business owner(s), all individuals providing services to the business are obtained from a registered temporary service agency and that agency has covered these individuals for New York State disability benefits insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation. 6. That if circumstances change so that workers' compensation insurance and/or disability benefits coverage is required, such as the hiring of employees, the above-named business will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers' Compensation Board to the government entity listed in item 3 on the front ofthis form. 7. That based on the facts presented, I certify that the above-named business does not require (check box 7a. and/or 7b.): LJ 7a.) workers' compensation insurance. (applicant must have checked ONE of the boxes from 4a. through 4h.) LJ 7b.) disability benefits insurance. (applicant must have checked ONE ofthe boxes from Sa. through Sf.) 8. By signing my name below, I hereby affirm that the statements made herein are true, that I have not made any materially false statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that aqy false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accQlrdance with the Workers' Compensation Law and all other New York State laws. (Applicant's Signature --first and last name) Sworn to before me this Day of ,20_ Notary Public NYS Workers' Compensation Board Received Stamp Because this is a sworn affidavit, employees ofthe Workers' Compensation Board cannot assist applicants in answering questions about this form. WCIDB 100 (12/03) {Replaces C-105.21 Form} -4- (Over) NYS WCB NYS WCB NYS WCB NYS WCB NYS WCB WClDB1001101 NYS WCB NYS WCB NYS WCB WClDB 1 0011 01 WCIllB1001101 WClDB1001101 WClDB1001101 107 WClDB1001101 NYS WCB WClDB1001101 WClDB1001101 168-46 91st NYS WCB 100 Broadway State OIlice 111 Livingston Delaware 220 Rabro WClDB1001101 215 W. 125111 41 North Ave. WClDB1001101 NYS WCB Menands Building St Ave. Drive 175 Fulton 51. Division 51. 3rd Floor 130 Main 51. WClDB100/101 ALBANY 44 Hawley Street 22nd Floor BUFFALO Suite 100 Ave. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 James St 12241 BINGHAMTON BROOKLYN 14202 HAUPPAUGE HEMPSTEAD NEW YORK 10566 11432 14614 SYRACUSE (866) 750- 13901 11201 (866) 211- 11788 11550 10027 (866) 746- (800) 877- (866) 211- 13203 5157 (866) 802-3604 (BOO) 877-1373 0645 (866) 681-5354 (866) B05-363O (BOO) 877-1373 0552 1373 0644 (866) 802-3730 F.... (518) FaJdI (607) FaJdI (718) FaJdI (716) F.... (631) FaJdI (516) FaJdI (212) FaJdI (914) FaJdI (718) FaJdI(585) FaJdI (315) 423- 473-9166 721~324 802.$42 842-2132 952-7966 560-7807 316-9183 788-5793 291-7248 238~351 2938 - ) , **This form cannot be used to waive the workers' compensation rights or obligations of any party including a subcontractor * * The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers' compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at the fax number or address listed on the top of this form. Incomplete forms will be returned. Please note: This statement must be notarized and also have been stamped by the New York State Workers' Compensation Board. This affidavit will not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WC/DB-IOI form, the Workers' Compensation Board will stamp this form as received and return it to you by either mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which you are requesting a permit, license or contract. In the Application of (Business Name and Address) for a permit/license/contract County of ) ) sS.: ) State of (applicant's name) being duly sworn, deposes and says: 1. I am the (position) with (business or trade name), a (type of business). The telephone number of the business is ( The Federal Employer Identification Number of the business (or the Social Security Number of the business owner) is . The New York State Unemployment Insurance Employer Registration Number (if any) of the business is . I affirm that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address IS number is ~ and my home telephone Location of (type of perm it/ /icense/contract (governmental entity issuing the perm it/ /icense/contract). wi\l be performed in New York State from to __ (dates with permit/license/contract). The estimated dollar amount of project is where work 3. That the above named business is applying for a applyingfor} from 3a) {Optional necessary to complete work associated .J 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check either box 4a or 4b): WCIDB-IOI (12/03) {Replaces C-IOS.21 Form} -5- (Over) C] 4a) the business is from outside of New York State, and wishes to use its foreign or other state's workers' compensation insuran( policy to cover its employees while they are working in New York State. To check this box, the applicant ~ have New YOI (NY) specifically listed on Item 3C on the Information Page of its workers' compensation insurance policy (Exeeption-3C covera! not required/or contracts where ALL work is done outside of New York State), and MIlSI attaclt a certificate of insurance from i foreign or other State's workers' compensation insurance policy to this Affidavit (and listed the governmental entity issuing tf. permit! license/contract as the Certificate Holder). Further, by checking box "4a" on this form, the applicant C;l$/lTIFlES tltatlc the period covered by this exemption for", the above business DOES NOT or WILL NOT meet any of the following four criteri (400. - 4ad.). 4aa. has a physical location within New York State, nor 4ab. has more than $50,000 in labor costs in a calendar year for employees and subcontractors working in New York Stale!, nor 4ac. has one or more employees (including subcontractors) with a primary work location or hired within New York State. nor 4ad. has an employee or employees (including subcontractors) working in New York State more than 90 days in a calendat year. Applicants that meet any of the above four criteria (4aa. - 4ad.), CANNOT check "box 4a" on this form and CANNOT file thi form for a workers' compensation exemption. PLeASE NOTE: Applicants tltat meet any oftl1e abovefour criteria, (400. - 4ad.), ar REQUIRED to Itave a full New York State workers' compensation policy (NY listed under Item 3A on tlte l1ifortnation Page of tit insurance policy) and mustfile eitlter a C-I05.2 - Certificate of Workers' Compensation Insurance OR a U-26.3, Ut~ State Insuranc, Fund's version 0/ tl1is form (l11e business' insurance carrier will send tltese forms to the government entity issuing tf,e permit, /icens, or contract upon tlte business' request) as proof of this coverage. [Applicants that DO NOT meet alt)' oftlte abovejour criteria (4aQ - 4ad.) are NOT required to Itave NY listed ultder Item 3A on the Information Page oftl1e insurance policy. Insteul/, the out-of-stat, employer's employees will be covered when working in New York by having NY listed in Item 3C on tlte Iliform_tion Page of tit, workers' compensation insurance policy (the other-states section).} (j 4b) All employees from the entity applying for the permit, license or contract are direct employees of a governmen~ entity outside 0 New York State and such employees are outside the jurisdiction of New York State workers' compensation coverage. (Applican MllSI attach a certificate of insurance from its foreign or other State's workers' compensation insurance policy to' this Affidavit) 5. That the above named business is certifying that it is exempt from obtaining New York State disability benefits insurl1nce coverage fOJ the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from 511. through 5b.): (j Sa.) the business does not require disability benefits coverage at this time since it has not employed one or more individuals on a' least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under thi Disability Benefits Law.) (j 5b.) All employees from the entity applying for the permit, license or contract are direct employees of a government entity outside oj New York State and such employees are outside the jurisdiction of New York disability benefits coverage. 6. That if circumstances change so that workers' compensation insurance and/or disability benefits coverage is required, the above- named business will immediately acquire appropriate New York State specific workers' compensation insurance ,and/or disability benefits coverage and also immediately fiunish proo; of that coverage on forms approved by the Chair of the Workers' Compensation Board to the government entity listed in item 3 on the front of this form. 7. That based on the facts presented, I certify that the above-named business does not require (check box 7a. and/or 7b.): Ll 7a.) workers' compensation insurance. (applicant must have checked box 4a or 4b and attached a certificate of insurance from its foreign or other State's workers' compensation insurance policy to this Affidavit) o 7b.) disability benefits insurance. (applicant must have checked either box 5a.or 5b.) 8. By signing my name below, I hereby affirm that the statements made herein are true, that I have not made any materially false statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that any false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in acedrdance with the Workers' Compensation Law and all other New York State laws. (Applicant's Signature --first and last name) Sworn to before me this Day of ,20_ Notary Public Because this is a sworn affidavit, employees of the Workers' Compensation Board cannot assist applicants in answering questions about this form. WCIDB-tOt (12/03) {Replaces C-105.2t Form} -6- (Over) STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. EMPLOYER'S APPLICATION FOR CERTIFICATE OF COMPLIANCE WITH DISABILITY BENEFITS LAW INSTRUCTIONS TO EMPLOYER: Complete PART 1 ONLY and have your Disability Benefits Insurance Carrier complete Part 2. PART 1. TO BE COMPLETED BY EMPLOYER EMPLOYER'S NAME AND ADDRESS (Home or Main Office) LOCATION OF OPERATIONS NAME UNDER WHICH BUSINESS IS CONDUCTED, IF DIFFERENT FROM ABOVE DISABILITY BENEFITS CARRIER (If more than one, list all) Application is hereby made to the CARRIER for a Certificate of Compliance with the Disability Be Tel. No:. 1___._________________ Title________________ PART 2. CERTIFICATE OF COMPLlA This is to certify that the above employer is insured with_______ and that the polley covers: . a. 0 ALL of the EMPL Date Signed_____ I gnature of carrier's authorized representative (currently on file with DB Bureau)) Tel. No:. L__._ ETE. Mail it directly to the employer. . NO COMPLETE for purposes of Section 220. subd. 8 of the Disability Benefits Law. It must be mailed for tion Board, Disability Benefits Bureau, 100 Broadway Menands, Albany, NY 12241-0005. PART 3. ED BY WORKERS' COMPENSATION BOARD (Only if box "b" of Part 2 has been checked) STATE OF NEW YORK WORKERS' COMPENSATION BOARD There is on file with the Workers' Compensation Board, Certificate of Insurance indicating that the above-named employer has complied with the Disability Benefits Law with respect to all of his/her employees. DISABILITY BENEFITS BUREAU Date Signed By Tel. No:. I_I Title DB-120.1 (4-99) -7- STATE OF NEW YORK WORKERS' COMPENSATION BOARD DISABILITY BENEFITS LAW CERTIFICA TE/CANCEllA TION OF INSURANCE Filed on behalf of Employer in compliance with Article 9 of the Workers' Compensation Law Transaction I Effective Date: 10. EMPLOYER'S LEGAL NAME. INCLUDING (DBAlAKAfTA) 11. ADDRESS 12. CITY STATE ZIP CODE 22. ADD~ESS 28. POLICYHOLDER ADDRESS 23. CITY 29. CITY STATE ZIPC DE 24. EMPLOYER FEIN 30. POLICYHOLDER FEIN 26. POLICY NUMBER G. 1. ployees as follows: under the New York State Disability Benefits Law. b. Ie under the New York State Disability Benefits Law except those classes of employees eligible to receive bene under another policy or plan accepted by the Chair. < - 10nlY !he followil1!1 class 0' classes of employee" 2. The employee contributions required and benefits insured are: a. _ The same in all respects as under Section 204 and not in excess of those authorized under Section 209. b. _ As described in the attached supplement, Form DB820.1. c. _ As described in Employers Application for Acceptance of a Plan. Form DB800, filed with and accepted by the Chair. d. As described in Certificate of Insurance, Form DB820.3, filed on behalf of the Association, Union or Trustees (policyholders) on or amended Form DB820.3 filed thereafter. DATE To be filed by Insurance Carrier on behalf of Employer to provide, through insurance, exactly statutory benefits, (Section 204) OR benefits under a plan accepted by the the Chairman. DB 820/829 (4-03) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABIUTIES WITHOUT DISCRIMINATION -8- . '~~r ~..~'~l"" 'r~, t~'~ ".;:" ~-.:-.;:' '.' ':'~"'.i - "" ...,~.",. -~..,. - . E:Xq:LS\OV- STATE OF NEW YORK WORKERS' COMPENSATION BOARD SELF-INSURANCE OFFICE 20 PARK STREET - r.aOM 201 ALBAN NY 12207 THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINA TION. ROBERT R. SNASHALL CHAIRMAN EMPLOYER ADDRESS (HOME OR MAIN OFFICE) OUT: rsuant to Sec. 211, ubd. 3 of the ed insurance carrieres). Date: W.e. Examiner DB-155 (1/98) -9- November 3, 2003 WORKERS' COMPENSATION REQUIREMENTS UNDER WCL ~57 To comply with coverage provisions of the Workers' Compensation Law, businesses must: A) be legally exempt from obtaining workers' compensation insurance coverage; or B) obtain such coverage from insurance carriers; or C) be self-insured or participate in an authorized group self-insurance plan. To assist State and municipal entities in enforcing Section 57 of the Workers' Compensation Law, businesses requesting permits or seeking to enter into contracts MUST provide ONE of the following forms to the government entity issuing the permit or entering into a contract: A) WC/DB-100, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required; OR N~~-~'{ori$i"SiCi/ . .....;\~8~.;lft~qyire ..~'\cifiC!~Jt~y.r.)' oris ..~t.~te_.WQrJsE;rs.'..QQmpens9ti90 8.ii~LQr~Qi?,~Rm ..tc___._,~.Jt~Jn~Ur,~D~~-_......~L~9~; OR (Affidavits must be stamped as received by the NYS Workers' Compe~sation Board) B) C-I05.2 -- Certificate of Workers' Compensation Insurance (the business' insurance carrier will send this form to the government entity upon request) PLEASE NOTE: The State Insurance Fund provides its own version of this form, the U-26.3; OR C) SI-12 -- Certificate of Workers' Compensation Self-Insurance (the business calls the Board's Self- Insurance Office at 518-402-0247), OR GSI-105.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance (the business' Group Self-Insurance Administrator will send this form to the government entity upon request). DISABILITY BENEFITS REQUIREMENTS UNDER WCL ~220 SUBD 8 To comply with coverage provisions of the Disability Benefits Law, businesses may: A) be legally exempt from obtaining disability benefits insurance coverage; or B) obtain such coverage from insurance carriers; or C) be self-insured. Accordingly, to assist State and municipal entities in enforcing Section 220 Subd. 8 of the Disability Benefits Law, businesses requesting permits or seeking to enter into contracts MUST provide ONE of the following forms to the entity issuing the permit or entering into a contract: A) WC/DB-100, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required; OR (Affidavits must be stamped as received by the NYS Workers' Compensation Board) B) Either the DB-120.1 -- Certificate of Disability Benefits Insurance OR the DB-820/829 Certificate/Cancellation ofInsurance (the business' insurance carrier will send one of these forms to the government entity upon request); OR C) DB-155 -- Certificate of Disability Benefits Self-Insurance (the business calls the Board's Self- Insurance Office at 518-402-0247). -. * PRESENTATION OVERVIEW -$'- WORKERS' COMPENSATION LAW -- SECTIONS 57 AND 220 SURD. 8 1. Definition of Workers' Compensation and Disability Benefits + wc covers job related accidents, injuries, illnesses -- Benefits 2/3 average weekly wage up to $400 per week plus all related medical expens.es. + DB covers non-job related accidents, injuries, illnesses -- Benefits 1/2 average weekly wage up to $170 per week for maximum of26 weeks; NO medical expenses. 2. How this insurance benefits both employers and employees + Employees -- No fault, "prompt payment" of benefits . Employers -- Sole remedy coverage - "eliminates" lawsuits and personal liability 3. Why municipal or State employees have to check on this insurance coverage . 957 & 9220 WCL requirement . Part of public protection responsibilities 4. What happens ifan employer is supposed to have this coverage and doesn't . Employer personally liable for full compensation and medical claim payments; penalties; administrative expenses; and possible criminal charges. . Employee initially paid by Uninsured Employer's Fund -- a process that takes two to three years before compensation or medical bills are paid. 5. How municipal or State employees check on this insurance coverage (Please note: businesses must supply appropriate formes) once per year) WC & DB . WCIDB-l 00, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Com ensation And/Or Disabili Benefits Insurance Coverage Is NotRe uired; OR WCIDB-10l, ,f.. j NYS Workers' Compensation Board); WC + C-105.2 _ Certificate of Worker's Compensation Insurance (the business' insurance carrier will send this form to the government entity upon the business' request) PLEASE NOTE: The State Insurance Fund provides its own version of this form, the U-26.3; OR WC + SI-12 -_ Certificate ofW orker' s Compensation Self-Insurance, GSI-I 05.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance (please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!) DB + Either the DB-120.1 -- Certificate of Disability Benefits Insurance OR the DB-820/829 Certificate/Cancellation oflnsurance (the business' insurance carrier will send one of these forms to the government entity upon request); OR DB + DB-l 55 -- Certificate of Disability Benefits Self-Insurance. ; (Affidavits must be stamped as received by the 6. Out-of-state employers need specific NYS workers' compensation coverage if they meet any of the following criteria: + Permanent NYS Location + Hire an employee (or subcontractors) in NYS + Pay over $50,000 per year to employees while they work in NYS + Employees (or subcontractors) assigned to work over 90 days in NYS during a calendar year. Disability benefits coverage is required if the business employs individuals in NYS for more than 30 days in a calendar year. 7. General Contractors/Independent Contractors/Subcontractors + General Contractors must get a workers' compensation insurance policy if they hire any subcontractors or independent contractors. 8. Are homeowners required to submit proof of workers' compensatIon insurance prior to the homeowner receiving a building permit? (New Law __ Chapter 439 of the Laws of 1998 -- General Municipal Law,Chapter 125) For homeowners of a 1, 2, 3, or 4 family, Owner-occupied Residence, proof of their exemption from the mandatory coverage provisions of the Workers' Compensation Law when applying for a building permit is to file a [onn 'sP-1 (3/99). · Form BP-I (3/99) shall be filed if the homeowner of a 1,2,3 or 4 Family, Owner-occupied Reside~<le is listed as the general contractor on the building permit, and the homeowner: · is performing all the work for which the building permit was issued himlherself, · is not hiring, paying or compensating in any way, the individual(s) that is(are) performing all tIne work for which the building permit was issued or helping the homeowner perform such work, or · has a homeowner's insurance policy that is currently in effect and covers the property for which the building permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 hou~s per week (aggregate hours for all paid individuals on the jobsite) for the work for which the building pennit was issued. · If the homeowner of aI, 2, 3 or 4 Family, Owner-occupied Residence is hiring or paying individuals~. total of 40 hours or MORE in any week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeowner may not file the "Affidavit of Exemption" form, BP-l (3/99), but shall either: · acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity i$suing the building permit (the C-I 05.2 or U-26.3 form), OR · have the general contractor, (performing the work on the 1, 2, 3 or 4 family, .owner-occupied residence (including condominiums) listed on the building permit) provide appropriate proof of workers' co~pensation coverage, or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit. 9. What is the municipal or State employees' personal liability if they forget to get proof of these coverages? · No direct liability under Section 57 for payment of no-insurance claims. However, nothing precludes an injured individual from filing a direct lawsuit for failure to perform public responsibilities. ' 10. What is the municipal or State agency's liability if municipal or State employees forget to get proof of these coverages? · No liability under Section 57 for payment of no-insurance claims. However, nothing precludes an injured individual from filing a direct lawsuit for failure to perform public responsibilities. Please not~: if the municipality or State agency is directly hiring independent contractors or subcontractors, to avoid workers' compensation liability, the municipality should always require that the independent contrl'lll:tors or subcontractors have a workers' compensation insurance policy. Disclaimer: The preceding was solely provided for informational purposes. Only the Board, in its adjudicatory function, is authorized to determine entitlement to benefits based on the specific facts of a case and its application of the Law.