Untitled (2)
Cc.
S "'.f lC '),t h{,J.1J\
STATE OF NEW YORK
WORKERS' COMPENSA nON BOARD
20 PARK STREET
ALBANY, NY 12207
THIS AGENCY EMPLOYS AND SERVES
PEOPLE wrrn DISABILITIES wrrnoUT
DISCRIMINATION.
H
JEFFREY R. SWEET
ACTING CHAIRMAN
November 3,2003
Dear Government Official:
Sections 57 and 220 Subd. 8 ofthe Workers' Compensation Law (WCL) require the heads of all municipal and State
entities to ensure that businesses applying for permits, licenses or contracts have appropriate workers' compensation
and disability benefits insurance coverage. This requirement applies to both original issuances and renewals, and also
applies whether the governmental agency is having the work done or is simply issuing the permit, license or contract.
It is interesting to note that these Sections of the Law are not new. In fact, Section 57 was originally enacted by the
Legislature and signed by the Governor in 1922!
I am pleased to inform you that the Workers' Compensation Board is working to make it as easy as possible for
businesses, their insurance carriers, municipalities and State agencies to comply with the Law. Enclosed is
documentation that will further clarify requirements under Sections 57 and 220 Subd. 8 of the WCL, including the
revised forms that should be used immediately to carry out the Law. Please note that ACORD forms are NOT
acceptable proof of New York State workers' compensation or disability benefits insurance coverage!
Ensuring that businesses, receiving permits, licenses or contracts from municipal and State agencies, comply with the
Workers' Compensation Law protects both injured workers and employers. In addition, such oversight helps to level
the playing field, by strictly enforcing the requirement that all businesses maintain mandatory insurance coverages.
Municipal and State agency cooperation in enforcing Sections 57 and 220 Subd. 8 of the Workers' Compensation Law
is a critical component of encouraging business compliance.
Also enclosed is a copy of the new Section 125 General Municipal Law that requires aU applicants to provide proof
of workers' compensation compliance when applying for a building permit
Please note that the existing C-105.2l form will become obsolete as of December 1,2003. This package contains
extra copies of the new WCIDB-l 00 and the WCIDB-l 01 forms, which together replace the C-l 05.21 form. Form
WCIDB-100 and Form WCIDB-10l are affidavits and will be used starting December 1,2003. To be valid, the
WCIDB-100 and Form WCIDB-101 must be notarized and also stamped as received by the NYS Workers'
Compensation Board. An extra copy of the BP-l form is also included. Form WCIDB-l 00, Form WCIDB-l Oland
Form BP-l are the only three forms that Municipal and State agencies may reproduce themselves and distribute as part
of this process. You may make as many additional copies of these forms as you require. The enclosed instruction
pac~et will identify where applicants may obtain the other forms used to enforce these sections of the Workers'
Compensation Law. (An overview of all approved forms is included on the back of this letter.)
Revised Form C-105.2 (12-03) is effective December 1,2003. Earlier-dated versions of the form are obsolete
and should no longer be issued by insurers or accepted by governmental agencies after that date.
I would appreciate your notifying the permit-issuing, license-issuing and contract-making agencies or departments
within your jurisdiction of these requirements so that they may comply with the Law. If you have any questions or
require additional information, please feel free to call Steve Carbone of the NYS Workers' Compensation Board,
Bureau of Compliance at (518) 486-6307.
Thank you for your help in enforcing these Sections of the Workers' Compensation Law.
Sincerely,
~
November S, 2003
WORKERS' COMPENSATION REQUIREMENTS UNDER WCL ~S7
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,! ~usinesses
requesting permits or seeking to enter into contracts MUST orovide ONE ofthe following forms to the tovernment
entity issuing the permit or entering into a contract:
A) WC/DB-1 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 C~verage Is
Not Required; OR
WCIDB-t01,
(Affidavits must be stamped as received by the NYS Workers' Compensation Board)
B) C- 105.2 -- Certificate of Workers' Compensation Insurance (the business' insurance canierwillsend 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 j .
C) SI-12 -- Certificate of Workers' Compensation Self-Insurance (the business calls the Bo~d's Self-
Insurance Office at 518-402-0247), OR GSI-I05.2 - Certificate of Participation in Worker's
Compensation Group Self-Insurance (the business' Group Self-Insurance Administrator wil~ 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 pennits or seeking to enter into contracts MUST orovide ONE of the following fo~ to the
entity issuing the permit or entering into a contract:
A) WCIDB-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 Cov~rage Is
Not Required; OR
WCIDB-101,
(Affidavits must be stamped as received by the NYS Workers' Compensation Board)
B) Either the OB-120.1 -- Certificate of Disability Benefits Insurance OR the DB-$20/829
Certificate/Cancellation of Insurance (the business' insurance carrier will send one of these fQ~s to the
government entity upon request); OR
C) OB-155 - Certificate ofOisability Benefits Self-Insurance (the business calls the Board's Self-Insurance
Office at 518-402-0247).
NYS WCB NYS WCB
NYS WCB NYS WCB NYS WCB WClDBl 0011 01 NYS WCB NYS WCB NYS WCB WClDBl 0011 01
WClDB1 0011 01 WCIOB1001101 WClDB1001101 107 WClDB1001101 NYS WCB WClDB1001101 WClDBl 0011 01 16B.4691st NYS WCB
100 Broadway State Office 111 Livingston Delaware 220 Rabro WClDB1001101 215 W. 125th 41 North Ave. WClDB1001101 NYS WCB
Menands Building SI. Ave. Drive 175 Fulton SI. Division SI. 3rd Floor 130 Main SI. WClDB1001101
ALBANY 44 Hawley Street 22nd Floor BUFFALO Suite 100 Ave. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 James 51.
12241 BINGHAMTON BROOKLYN 14202 HAUPPAUGE HEMPSTEAD NEW YORK 10566 11432 14614 SYRACUSE
(866) 75D- 13901 11201 (866)211- 11788 11550 10027 (866) 7l16- (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) FaX# (716) FaX# (631) Fax# (516) FaX# (212) FaX# (914) FaX# (718) FaX# (585) . FaX# (315) 423-
473-9166 721-8324 802-6642 842-2132 952-7966 56D-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 conmct an attorney if you have any questions regarding this form.)
**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 stamlJed 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 WClDB 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
permitlIicense/contract
County of
)
) S5.:
)
State of
(applicant's name) being duly sworn, deposes and says:
(position) with (business or trade
(type of business). The telephone number of the business is (-)
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
(-)
3. That the above named business is applying for a
applying for) from
3a) (Optional
name), a
The Federal
1.
I
am
the
. I affirm
number is
(type of permit! licenselcontract
(governmental entity issuing the permit! licenselcontract).
will be performed in New York State
from to (dates necessary
to complete work associated with permit/licenselcontract). 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 attIlch separate sheet with a list of aU the partners names and also with the siglUltures of aU 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
WC/DB 100 (12/03) {Replaces C-105.21 Form}
(Over)
LJ 4d.) the business is a two person owned corporation, with those individuals owning all of the stock and hOldi"g all ~ffices of the
corporation (each individual must own at least one share of stock). Other than the corporate owners, there are nq employees, leased
employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family menilbers). (Must aUach
separate sheet with a list of the names of both owners, and also with both owners' signatures.)
LJ 4e.) the applicant is a nonprofit entity (under IRS rules). With the exception of clergy or teachers, the nonprofit ~ais no compensated
individuals or subcontractors providing any services.
LJ 4f.) the business is a farm with less than $1,200 in payroll the preceding calendar year.
LJ 4g.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personall residence. Onlv
uncompensated friends/family are helping to build this structure. i
LJ 4h.) other than the business owner(s) and individuals obtained from a registered temporary service agency, thereiare no employees,
leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including famil~ members). Other
than the business owner(s), all individuals providing services to the business are obtained from a registered tempo$ry service agency
and that agency has covered these individuals for New York State workers' compensation insurance. In additi~~I, 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 pne 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.):
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 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 indivi~uals on at least 30
days in any calendar year in New York State. (Independent contractors are not considered to be employees urlrJer the Disability
Benefits Law.)
LJ 5b.) the applicant is a political subdivision that is legally exempt from providing statutory disability benefits coverag~:
LJ 5c.) the applicant is a nonprofit religious, charitable or educational institution. With the exception of executivb 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 bmployeer' Other
than the business owner(s), all individuals providing services to the business are obtained from a registered temporalry service agency
and that agency has covered these individuals for New York State disability benefits insurance. In addition, the bus~ness 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.t~<) 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, ~uch as the hiring
of employees, the above-named business will immediately acquire appropriate New York State specific workers' compe~sation insurance
and/or disability benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chai~ 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.)
LJ 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 faIse
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 acc~rdance 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 . eceived Stamp
Because this is a sworn affidavit, employees of the Workers' Compensation Board cannot assist applicants in answering questions about this form.
WC/DB 100 (12/03) {Replaces C-105.21 Form}
(Over)
NYS WCB NYS WCB
NYS WCB NYS WCB NYS WCB WClDB1001101 NYS WCB NYS WCB NYS WCB WClDBl 0011 01
WClDB1001101 WClDB1 0011 01 WClOB1001101 107 WClOB1001101 NYS WCB WClDB1001101 WClOB1001101 168.4691st NYS WCB
100 Broadway State Office 111 Livingston Delaware 220 Rabro WClDB1001101 215 W. 125th 41 North Ave. WClDB1001101 NYS WCB
Menands Building SI. Ave. Drive 175 Fulton SI. Division SI. 3rd Floor 130 Main SI. WClDB1001101
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) 75D- 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) FaX# (718) FaX# (716) FaX# (631) FaX# (516) FaX# (212) FaX# (914) Faldl (718) Fax# (585) . Faldl (315) 423-
473-9166 721-8324 802-6642 842-2132 952-7966 56D-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 Jorm cannot be used to waive the workers' compensation rights or obligations oj 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 staml1ed 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 tOO 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
permitllicense/contract
State of
)
) ss.:
)
County of
(applicant's name) being duly sworn, deposes and says:
(position) with (business or trade
(type oj business). The telephone number of the business is (_)
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
<-)
3. That the above named business is applying for a
applying for) from
3a) (Optional
1.
I
am
the
name), a
The Federal
. I affirm
number is
(type oj permitllicense/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 anach 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
WC/DB 100 (12/03) {Replaces C-105.21 Form}
(Over)
Ll 4d.) the business is a two person owned corporation, with those individuals owning all of the stock and holdi~g all ~ffices of the
corporation (each individual must own at least one share of stock). Other than the corporate owners, there are nq employees, leased
employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family me~bers). (Must aUach
separate sheet with a list of the names of both owners, and also with both owners' signatures.) i
Ll 4e.) the applicant is a nonprofit entity (under IRS rules). With the exception of clergy or teachers, the nonprofit ~as 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.
o 4g.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal I residence. Onlv
uncompensated friends/family are helping to build this structure. i
I
Ll 4h.) other than the business owner(s) and individuals obtained from a registered temporary service agency, therelare no employees,
leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including fami~memberS)' Other
than the business owner(s), all individuals providing services to the business are obtained from a registered tempo .. service agency
and that agency has covered these individuals for New York State workers' compensation insurance. In additi ~I, 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 ~>ne 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 insutance coverage for
the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from 5a.lthrough 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 corpbration; or is a one
or two person owned corporation, with those individu8Is owning all of the stock and holding all offices of the Corp~tion. In addition,
the business does not require disability benefits coverage at this time since it has not employed one or more indivi uals on at least 30
days in any calendar year in New York State. (Independent contractors are not considered to be employees U 'er the Disability
Benefits Law.) i
LlSb.) the applicant is a political subdivision that is legally exempt from providing statutory disability benefits coverag~:
Ll Sc.) the applicant is a nonprofit religious, charitable or educational institution. With the exception of executiv~ officers, clergy,
sextons, teachers or professionals, the nonprofit has no compensated individuals providing services. '
Ll5d.) 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 r~:sidence. Onlv
uncompensated friends/family are helping to build this structure. ,
LlSf.) other than the business owner(s) and individuals obtained from the temporary service agency, theI.".are no otherlemployees. Other
than the business owner(s), all individuals providing services to the business are obtained from a registered tempor~ry service agency
and that agency has covered these individuals for New York State disability benefits insurance. In addition, the bustness 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. tfo person owned
corporation, with those individuals owning all of the stock and holding all offices of the corporation. I
6. That if circumstances change so that workers' compensation insurance andlor disability benefits coverage is required, ,sli!ch as the hiring
of employees, the above-named business will immediately acquire appropriate New York State specific workers' compersation insurance
andlor disability benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chait IOf the Workers'
Compensation Board to the government entity listed in item 3 on the front of this form. i
7. That based on the facts presented, I certify that the above-named business does not require (check box 7a. andlor 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 tme, that I have not made anYllWlteriaUy false
statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that an~ false statement,
representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accprdance with the
Workers' Compensation Law and all other New York State laws. :
(Applicant's Signature -- first and last name) -1-----
I
Sworn to before me this _
Day of , 20_
Notary Public
NYS Workers' Compensation Board; eceived Stamp
Because this is a sworn affidavit, employees ofthe Workers' Compensation Board cannot assist applicants in answering question~ ~bout this form.
WC/DB 100 (12/03) {Replaces C-105.21 Form}
(Over)
NYS WCB NYS WCB
NYS WCB NYS WCB NYS WCB WClD81001101 NYS WCB NYS WCB NYS WCB WCl08100/101
WClD8100/101 WCl081001101 WClD81oo1101 107 WClD81oo1101 NYS WCB WClD81 0011 01 WClD8100/101 168-4691st NYS WCB
10D Broadway State Office 111 Livingston Delaware 220 Rabro WCl081001101 215 W. 125th 41 North Ave. WCl08100/101 NYS WCB
Menands Building SI. Ave. Drive 175 Fulton SI. Division SI. 3rd Floor 130 Main SI. WClD8100l101
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)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) Fax# (718) FaX# (716) FaX# (631) FaX# (516) FaX# (212) FaX# (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
~fftdavitwnaf"An}.G)tfJJ;.<3E~S$A::r;;E~:@ffiE,ORElGN:~' . - R~Wotkln'.' ~'lfiiNeV{.:~.o:rK{<State;;tD~esjNor~Et. uire
< .' . 'S~~'@fl6.!N1~~6r~St~1w'5ik~t~~~c'&m'~€~a >O~~Drs~biITt0B~nefi~517i'1tirab~~e~~Eir~~~
(Incomplete forms will be returned - Please contact an attorney if you have any questions regarding this form.)
**Thisform 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-IOl 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
where
work
(type of permit/ licenselcontract
(governmental entity issuing the permit/ licenselcontract).
will be performed in New York State
from to (dates
estimated dollar amount of project is
3. That the above named business is applying for a
applying for) from
3a) (Optional
work associated with permit/licenselcontract). The
necessary to complete
. }
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):
WC/DB-IOl (12/03) {Replaces C-105.21 Form}
(Over)
D 4a) the business is from outside of New York State, and wishes to use its foreign or other state's workers' comJensation 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 (Exc !tion-3C coverage
not required for contracts where ALL work is done outside of New York State), and MUST attach a certificate 0 iJrzsurance from its
foreign or other State's workers' compensation insurance policy to this Affidavit (and listed the governmenta entity issuing the
permit! licenselcontract as the Certificate Holder). Further, by checking box "4a" on this form, the applicant that for
the period covered by this exemption form the above business DOES NOT or WILL NOT meet any of the fall wing four criteria
(4aa. - 4ad.).
4aa. has a physical location within New York State, nor 1
4ab. has more than $50,000 in labor costs in a calendar year for employees and subcontractors working in New York Statef nor
4ac. has one or more employees (including subcontractors) with a primary work location or hired within New York State, *or
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 qANNOT file this
form for a workers' compensation exemption. PLEASE NOTE: Applicants that meet any of the above four criteria~i4aa. _ 4ad.), are
REQUIRED to have a full New York State workers' compensation policy (NY listed under Item M on the Inform lion Page of the
insurance policy) and must file either a C-I05.2 -- Certificate of Workers' Compensation Insurance OR a U-26.3, th State Insurance
Fund's version of this form (the business' insurance carrier will send these forms to the government entity issuing t~e pe17Jlit, license
or contract upon the b'!siness' request) as proof of this coverage. [Applicants that DO NOT meet any of the abovejour criteria (4aa.
- 4ad.) are NOT required to have.NY listed under Item 3A on the Information Page of the insurance policy. InsteoJt" the out-of-state
employer's employees will be covered when working in New York by having NY listed in Item 3C on the Inform*tion Page of the
workers' compensation insurance policy (the other-states section).)
D 4b) All employees from the entity applying for the permit, license or contract are direct employees of a governmen~ entity outside of
New York State and such employees are outside the jurisdiction of New York State workers' compensation cov~rage. (Applicant
~attach a certificate of insurance from its foreign or other State's workers' compensation insurance policy tojthis Affidavit)
5. That the above named business is certifying that it is exempt from obtaining New York State disability benefits insur~nce coverage for
the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from 5a.1 through 5b.):
D Sa.) the business does not require disability benefits coverage at this time since it has not employed one or more li~ldividuals on at
least 30 days in any calendar year in New York State. (Independent contractors are not considered to be empllayees under the
Disability Benefits Law.)
D 5b.) All employees from the entity applying for the permit, license or contract are direct employees of a governmen~ 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 reqtl1ired, the above-
named business will immediately acquire appropriate New York State specific workers' compensation insurance ~l1d/or disability
benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Worker~' 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. andlor 7b.):'
D 7a.) workers' compensation insurance. (applicant must have checked box 4a or 4b and attached a certificate of in~lilrance from its
foreign or other State's workers' compensation insurance policy to this Affidavit) i
D 7b.) disability benefits insurance. (applicant must have checked either box 5a.or 5b.) .
I
8. By signing my name below, I hereby affirm that the statements made herein are true, that I have not made any ~aterialIy false
statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that any Ifalse statement,
representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accqrdance with the
Workers' Compensation Law and all other New York State laws. .
(Applicant's Signature -- first and last name) i
Sworn to before me this _
Day of , 20_
Notary Public
cel ve tamp
Because this is a sworn affidavit, employees of the Workers' Compensation Board cannot assist applicants in answering questions a~o~t this form.
WC/DB-101 (12/03) {Replaces C-105.21 Form}
(Over)
NYS WCB
NYS WCB NYS WCB NYS WCB NYS WCB NYS WCB NYS WCB WClDB100/101
WClDB100/101 WClDB100/101 WClDB100/101 WClDB100/101 NYS WCB WClDB100/101 WClDB1 0011 01 168-4691s1 NYS WCB
100 Broadway Slate Office 111 Livingston 220 Rabro WClDB1 0011 01 215 W. 125th 41 North Ave. WClDB100/101 NYS WCB
Menands Building SI. Drive 175 Fulton SI. Division SI. 3rd Floor 13D Main SI. WClDB1001101
ALBANY 44 Hawley Street 22nd Floor Suite 100 Ave. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 James SI.
12241 BINGHAMTON BROOKLYN HAUPPAUGE HEMPSTEAD NEW YORK 1D566 11432 14614 SYRACUSE
(866) 75D- 13901 11201 11788 11550 10027 (866) 746- (800) 877- (866) 211- 13203
5157 (866) 802-3604 (800) 877-1373 (866) 681-5354 (866) 805-3630 (800) 877-1373 0552 1373 0644 (866) 802-3730
FaX# (518) Fax# (607) Fax# (718) FaX# (631) FaX# (516) FaX# (212) FaX# (914) Fax# (718) FaX# (585) Fax# (315) 423-
560-7807 316-9183 788-5793 291-7248 238-8351 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 stamTJed 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-lOl 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:
L 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
where
work
(type of permit/license/contract
(governmental entity issuing the permit/license/contract)_
will be performed in New York State
from to (dates
estimated dollar amount of project is
3. That the above named business is applying for a
applying for) from
3a) [Optional
work associated with permit/licenselcontract). The
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):
WC/DB-lOl (12/03) {Replaces C-105.21 Form}
(Over)
o 4a) th, bus;n,,, ;s fcnm ou!S;d, nf N,w Yo,k Slate, and w;sbes to use;ts fm'.;gn 0' oth" Slate's wo,k",' c~~f'a,;on ;nsunmce
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 (Exce tion-3C coverage
not required for contracts where ALL work is done outside of New York State), and MUST attach a certificate 0 insurance from its
foreign or other State's workers' compensation insurance policy to this Affidavit (and listed the governmenta mtity issuing the
permit/ license/contract as the Certificate Holder). Further, by checking box "4a" on this form, the applicant that for
the period covered by this exemption form the above business DOES NOT or WILL NOT meet any of the follo ing four criteria
(4aa. - 4ad.).
4aa. has a physical location within New York State, nor i
4ab. has more than $50,000 in labor costs in a calendar year for employees and subcontractors working in New York State' ~lor
4ac. has one or more employees (including subcontractors) with a primary work location or hired within New York State, ar
4ad. has an employee or employees (including subcontractors) working in New York State more than 90 days in a calend )'ear.
Applicants that meet any of the above four criteria (4aa. - 4ad.), CANNOT check "box 4a" on this form and ANNOT 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 Inform non Page of the
insurance policy) and mustfile either a C-IOS.2 -- Certificate of Workers' Compensation Insurance OR a U-26.3, th State Insurance
Fund's version of this form (the business' insurance carrier will send these forms to the government entity issuing t ~~ per1Jlit, license
or contract upon the business' request) as proof of this coverage. [Applicants that DO NOT meet any of the above ur criteria (4aa.
- 4ad.) are NOT required to have NY listed under Item 1A on the Information Page of the insurance policy. Inste , the out-of-state
employer's employees will be covered when working in New York by having NY listed in Item 3C on the Inform, tion Page of the
workers' compensation insurance policy (the other-states section).] i
I
o 4b) All employees from the entity applying for the permit, license or contract are direct employees of a governmen~ entity outside of
New York State and such employees are outside the jurisdiction of New York State workers' compensation covbrage. (Applicant
MUS,T 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 insur~nce coverage for
the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE ofthe boxes from 5a.lthrough 5b.):
o Sa.) the business does not require disability benefits coverage at this time since it has not employed one or more lindividuals on at
least 30 days in any calendar year in New York State. (Independent contractors are not considered to be emplC'yees under the
Disability Benefits Law.) ,
o 5b.) All employees from the entity applying for the permit, license or contract are direct employees of a governmen~ entity outside of
New York State and such employees are outside the jurisdiction of New York disability benefits coverage. I
6. That if circumstances change so that workers' compensation insurance and/or disability benefits coverage is req~ired, the above-
named business will immediately acquire appropriate New York State specific workers' compensation insurance ~nd/or disability
benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Worker~' Compensation
Board to the government entity listed in item 3 on the front of this form. i
I
7. That based on the facts presented, I certify that the above-named business does not require (check box 7a. and/or 7b.):i
r:J 7a.) workers' compensation insurance. (applicant must have checked box 4a or 4b and attached a certificate of in~~lrance from its
foreign or other State's workers', compensation insurance policy to this Affidavit) i
r:J 7b.) disability benefits insurance. (applicant must have checked either box 5a.or 5b.) I
8. By signing my name below, I hereby affirm that the statements made herein are true, that I have not made any ~terialIY false
statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that any ifalse statement,
representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in acc9rdance with the
Workers' Compensation Law and all other New York State laws. i
I
(Applicant's Signature -- first and last name) I
Sworn to before me this _
Day of , 20_
Notary Public
I
I
Because this is a sworn affidavit, employees of the Workers' Compensation Board cannot assist applicants in answering questions a~aut this form.
WC/DB-101 (12/03) {Replaces C-105.2l Form}
(Over)
Affidavit of Exemption to Show Specific Proof of Workers' 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 if I 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 1,2, 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)
(County Clerk or Notary Public)
Property Address that requires the building permit:
BP-l (3/99)
LA WS OF NEW YORK, 1998
CHAPTER 439
The general municipal law is amended by adding a new section 125 to read as follows:
. 125. ISSUANCE OF BUILDING PERMITS. NO CITY, TOWN OR VILLAGE SHALL ISSUE A BUILDItrrG PERMIT
WITHOUT OBTAINING FROM THE PERMIT APPLICANT EITHER: I
I. PROOF DULY SUBSCRIBED THAT WORKERS' COMPENSATION INSURANCE AND DISABILI~lBENEFITS
COVERAGE ISSUED BY AN INSURANCE CARRIER IN A FORM SATISFACTORY TO THE CHAIR OF THE ORKERS'
COMPENSA TION BOARD AS PROVIDED FOR IN SECTION FIFTY-SEVEN OF THE WORKERS' COMPENSA JON LAW
IS EFFECTIVE; OR I
2. AN AFFIDAVIT THAT SUCH PERMIT APPLICANT HAS NOT ENGAGED AN EMPLOYER OR ANIt
EMPLOYEES AS THOSE TERMS ARE DEFINED IN SECTION TWO OF THE WORKERS ' COMPENSATION L4 W TO
PERFORM WORK RELATING TO SUCH BUILDING PERMIT.
Implementing Section 125 of the General Municipal Law
1. General Contractors and Business Owners .
For ~usinesse~ listed as the general contractors on building permits, proof that they are in compliance with ~ection 57 of
the Workers' Compensation Law (WCL) is ONE of the following forms that indicate that they are: I
· insured (C-105.2 or U-26.3),
· self-insured (SI-12), or
. are exempt (C-105.21),
under the mandatory coverage provisions of the WCL. Any residence that is not a 1, 2, 3 or 4 Family, Owner- cu ied
Residence is considered a business (income or potential income property) and must prove compliance by filing ne 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 mandat~ry coverage
provisions of the Workers' Compensation Law when applying for a building permit is to file form BP-l(3/99). !
i
· Form BP-l(3/99) shall be filed if the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence iJ llisted as the
general contractor on the building permit, and the homeowner:
.
o is performing all the work for which the building permit was issued him/herself,
o is not hiring, paying or compensating in any way, the individual(s) that is(are) performing all ~he work for
which the building permit was issued or helping the homeowner perform such work, or :
I
i
o has a homeowner's insurance policy that is currently in effect and covers the property for whichte building
permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 ho rs 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 l 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(3/9P), but shall
either: i
o acquire appropriate workers' compensation coverage and provide appropriate proof of that covera~e on forms
approved by the Chair of the NYS Workers' Compensation Board to the government entity lissuing the
building permit (the C-105.2 or U-26.3 form), OR I
I
o have the general contractor, (performing the work on the I, 2, 3 or 4 family, owner-OCCUPie}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 NY Workers'
Compensation Board to the government entity issuing the building permit. .
BP-l (3/99) Reverse
STATE & MUNICIPAL
AGENCY
REQUIREMENTS
UNDER
GENERAL MUNICIPAL LAW ~125
& WCL ~57 & ~220
FOR
WORKERS' COMPENSATION
AND
DISABILITY BENEFITS
Please call Steve Carbone at (518) 486-6307 if you have any questions.
f4ECE\\f
j: .'~"
'''-'-''/''1,\ C\ ER~'
~ \._)1, \.; : ~ l-'"
November 3, 2003
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
20 PARK STREET
ALBANY, NY 12207
TIllS AGENCY EMPLOYS AND SERVES
PEOPLE WITH DISABll..ITIES WITIlOUT
DISCRIMINATION.
JEFFREY R. SWEET
ACTING CHAIRMAN
November 3, 2003
Dear Government Official:
Sections 57 and 220 Subd. 8 of the Workers' Compensation Law (WCL) require the heads of all municipal and State
entities to ensure that businesses applying for permits, licenses or contracts have appropriate workers' compensation
and disability benefits insurance coverage. This requirement applies to both original issuances and renewals, and also
applies whether the governmental agency is having the work done or is simply issuing the permit, license or contract.
It is interesting to note that these Sections of the Law are not new. In fact, Section 57 was originally enacted by the
Legislature and signed by the Governor in 1922!
I am pleased to inform you that the Workers' Compensation Board is working to make it as easy as possible for
businesses, their insurance carriers, municipalities and State agencies to comply with the Law. Enclosed is
documentation that will further clarify requirements under Sections 57 and 220 Subd. 8 of the WCL, including the
revised forms that should be used immediately to carry out the Law. Please note that ACORD forms are NOT
acceptahle proof of New York State workers' compensation or disability benefits insurance coverage!
Ensuring that businesses, receiving permits, licenses or contracts from municipal and State agencies, comply with the
Workers' Compensation Law protects both injured workers and employers. In addition, such oversight helps to level
the playing field, by strictly enforcing the requirement that all businesses maintain mandatory insurance coverages.
Municipal and State agency cooperation in enforcing Sections 57 and 220 Subd. 8 of the Workers' Compensation Law
is a critical component of encouraging business compliance.
Also enclosed is a copy of the new Section 125 General Municipal Law that requires all applicants to provide proof
of workers' compensation compliance when applying for a building permit.
Please note that the existing C-I05.21 form will become obsolete as of December 1,2003. This package contains
extra copies ofthe new WCIDB-IOO and the WCIDB-I0l forms, which together replace the C-105.21 form. Form
WCIDB-IOO and Form WCIDB-IOI are affidavits and will be used starting December 1, 2003. To be valid, the
WC/DB-100 and Form WC/DB-101 must be notarized and also stamped as received by the NYS Workers'
Compensation Board. An extra copy of the BP-l form is also included. Form WCIDB-I 00, Form WCIDB-I 0 I and
Form BP-l are the only three forms that Municipal and State agencies may reproduce themselves and distribute as part
of this process. You may make as many additional copies of these forms as you require. The enclosed instruction
packet will identify where applicants may obtain the other forms used to enforce these sections of the Workers'
Compensation Law. (An overview of all approved forms is included on the back of this letter.)
Revised Form C-105.2 (12-03) is effective December 1,2003. Earlier-dated versions of the form are obsolete
and should no longer be issued by insurers or accepted by governmental agencies after that date.
I would appreciate your notifying the permit-issuing, license-issuing and contract-making agencies or departments
within your jurisdiction ofthese requirements so that they may comply with the Law. If you have any questions or
require additional information, please feel free to call Steve Carbone of the NYS Workers' Compensation Board,
Bureau of Compliance at (518) 486-6307.
Thank you for your help in enforcing these Sections of the Workers' Compensation Law~
Sincerely,
~
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,tlUsinesses
requesting permits or seeking to enter into contracts MUST provide ONE of the following fo nilS 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
B)
I
(Affidavits must be stamped as received by the NYS Workers~ Compensation Board) !
I
!
C-I05.2 -- Certificate of Workers' compensat.ion Insurance (the business' insurance c~r1rier will
send this form to the government entity upon request) PLEASE NOTE: The State Insur~nce Fund
provides its own version of this form, the U-26.3; OR !
SI-12 -- Certificate of Workers' Compensation Self-Insurance (the business calls the Boa~~I's Self-
Insurance Office at 518-402-0247), OR GSI-105.2 -- Certificate of Participation in IWorker's
Compensation Group Self-Insurance (the business' Group Self-Insurance Administrator r'iIl send
this form to the government entity upon request).
C)
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 muoicipal entities in enfnrcing Sectinn 220 Subd. 8 of the Disability I lIlenefits
Law, businesses requesting permits or seeking to enter into contracts MUST provide ONE of the ~lIowing
forms to the entity issuing the permit or entering into a contract: I
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 ~enefits
Insurance Coverage Is Not Required; OR I
WC/DB-101,
!
(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 DBJ20/829
Certificate/Cancellation oflnsurance (the business' insurance carrier will send one of these farms to
the government entity upon request); OR !
C) DB-155 -- Certificate of Disability Benefits Self-Insurance (the business calls the Boar1'1; Self-
Insurance Office at 518-402-0247).
WORKERS' COMPENSATION LAW
957. Restriction on issue of permits and the entering into contracts unless compensation is
secured.
1. 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 employment 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 has been secured as provided
by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or
municipal 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 required by law to
enter into any contract for or in connection with any work involving the employment of employees in a
hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or
authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance
carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as
provided by this chapter.
DISABILITY BENEFITS LAW
9220.Subd.8
(a) 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 employment of employees in employment as
defined in this article, and not withstanding 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 the payment of disability benefits for all employees has been secured as
provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such
state or municipal department, board, commission or office to pay any disability benefits to any such employee if
so employed.
(b) The head of a state or municipal department, board, commission or office authorized or required by law to
enter into any contract for or in connection with any work involving the employment of employees in
employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing
any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is
produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been
secured as provided by this article.