1987/2007 (14)NYS WCB
NYS WCB NYS WCB NYS WCB tNCioetoonot NYS WCB NYS WCB NYS WCB wcsoetoonot
tnraoetoonot tn~cioetoonot wrJOetoatot 107 tnrcmetttatot NYS WCB tnr~oatoatot trvcmetoawot 168691st NYS WCB
100 Broadway State Office 111 Livirtpaton Delaware 220 Ratio wc~oetoonot 215 W. 125th 41 North Ave. tnrcmettanot NYS WCB
Mettanda BuiMing St. Ave. Drive 175 Fulton St. Division St 3rd Floor 130 Main SL wc~oetoonot
ALBANY 44 Hawley Street 22nd Floor BUFFALO Suite 100 Ave. 3b Floor PEEKSKILL QUEENS ROCHESTER 935 James St.
12241 BINGHAMTON BROOIQYN 14202 HAUPPAUGE HEMPSTEAD NEW YORK 10586 11432 14614 SYRACUSE
(666>750- 13901 11201 (ess)z11- 11786 11550 1ooz7 (966)746- (600)877- (888)211- 13203
5157 (866) 802.9604 (800) 677-1373 0645 (886) 681.5354 (888)805-3630 (800) 877-1373 0552 1373 0844 (866)802.9730
FatuY (518) Fatd! (607) Pettit (718) Fax#t (718) Fatale (631) Faxtk (518)' Fault (212) Fa~att (814) FatrB (718) Fato1(585) Fax~Y (315) 423-
473-9166 7218324 802f842 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~Ard/Or Disability Benefits Insurance Coverage Is Not Required
(Incomplete jorins wiQ be returned -Please rnntad an attorney ijyou have any questions regarding this jornl.)
**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 othe
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 th
fax number or address listed on the top of this form. lncom~lete forms will be returned
Please note: This statement must be notarized and also have been s1~ by the New York State Workers' Compensation Board. This affidavi
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 100 form, the Workers' Compensation Board will stamp this form as received and return it to you by eithe
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 yot
are requesting a permit, license or contract.
In the Application of (Business Name and Address)
fora petmit/license/contract
State of )
ss..
County 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 Federa]
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 and my home telephone number is
U
3. That the above named business is applying fora (type of permit/ licenselcontract
applying for) from (governmental entity issuing thepermit/ license%ontract).
3a) {Optional - Location of where work will be performed in New York State
from to (dates necessary
to complete work associated with permit/license%ontract). 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.):
^ 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).
^ 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 aU thepartners names and also with the signatures of all thepartner~)
^ 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).
WC/DB 100 (12/03) {Replaces C-105.21 Form} _3_ (Over)
NYS WCB
NYS WCB
NYS WCB NYS WCB
wcmefoatot
NYS WCB
NYS WCB
NYS WCB NYS WCB
wrroetoonot
vvcmetoonot
DO Broadway wcmetoonot
State Office wcmatoonot
111 uvingston 107
Delaware rvcmetoatot
220 Rebro NYS WCB
wraoetoato wcroetoatof tnrcmetoonot 168-4691st NYS WCB
Menartds
Building
St
Aw.
Driw t
175 Fulton 215 W. 125th
St 41 North Aw. wanetoatof NYS WCB
ALBANY
44 Hawley Street
22nd Floor
BUFFALO
Suite 100
Aw.
3rd Floor Division St
PEEKSKILL 3rd Floor
QUEENS 130 Main St
ROCHESTER waoetoonot
12241
(866)750-
BINGHAMTON
13901
BROOKLYN
11201
14202
6
HAUPPAUGE
HEMPSTEAD
NEW YORK
10566
11432
14614 835 James St
SYRACUSE
5157
(8811) 8023604
(800) 877-1373 (
66)211-
0845 11788
(B68) 6815354 11550
(866)8053630 10027
(800) 877-1373 (ass)746-
0552 (800)877-
37 (866)211- 13203
FstcY (518)
473.9166
FaxB (607)
721-0324
Fa>ar (718)
tt02B[id9
Fa>d~ (718)
fid7_J1_Yl
Fatd~ (631)
os~_~oea
Faxl (516)
acti~erri
FawM (212)
~.e .-.,
FaxM (914)
--- -- 1
3
Fa>aM (718)
_-- -- 0644
FatcaK (585) (866) 8023730
Fawn (315) 423-
be returned -Please contact an adorney lfyou have any questions regarding
**77eis 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 WGDB-101 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
State of
County of
ss..
permiblicense%ontract
(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 affum 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 (_)
3. That the above named business is applying for a
applying for) from
3a) {Optional - Location of where work
and my home telephone
(type of permit/ license%ontract
_ (governmental entity issuing the permid license%ontract).
will be performed in New York State
from _to - (~t~
necessary to complete work associated with permidlicense%ontract). 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 either box 4a or 4b):
WC/DB-101 (12/03) {Replaces C-105.21 Form} _5_ (Over)
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
la. Legal Name and address of Insured (LJse street address only) lb. Business Telephone Number of Insured
lc. NYS Unemployment Insurance Employer Registration
Number of Insured
Work Location of Insured (Only required if coverage is specifically 1 d. Federal Employer Identi ion tuber of Insured or
limited to certain locations in New York State, i.e. a Wrap-Up Policy) Social Security Nu
2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Ca
Coverage (Entity Being Listed as the Certificate Holder)
3b. Po ' umber of entity listed in ':
icy a eriod:
~;
. T roprietor, P ers or Executive Officers are:
included. (Only check box if all parmers/officers included)
excluded or certain partners/officers excluded.
3e. Dem on is: (Dejmition of Demolition on Reverse)
^ ' eluded.
excluded.
This certifies that the insurance carrier indicat bove "insures the business referenced above in box "la" for workers'
compensation under the Ne ork State Workers' _ ensation . (To use this form, New York (NY) must be listed under
Item 3A on the INFO N PAGE of th or rs' compensation insurance policy). The Insurance Carrier or its
licensed agent will send this urance to the. ty listed above as the certificate holder in box " 2".
The Insurance Carrier will also- t~ the> holder within 10 days IF a policy is canceled due to nonpayment ofpremiums
or within 30 IF there are r o ther t payment of premiums that cancel the policy or eliminate the insured from the
coverage i n this Cert f (These noti may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of
one yea ter this m is appro the insurance carrier or its licensed agent
Please : Upon the ca tion of th ar rs' compensation policy indicated on this form, if the business continues to be named on a permit,
license o ertif older, the business must provide that certificate bolder with a new Certificate of Workers'
Compenss tho proof that the business is complying with the mandatory coverage requirements of the New York
State Workers' ComnensaNon
Under penalty of erjury, I ' y that I am an authorized representative or licensed agent of the insurance carrier referenced
above and that the red has the coverage as depicted on this form.
Approved by:
(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-IOS.2 form. Insurance brokers are NOT
authorized to issue it. _ ~
C-105.2 (12-03)
u~or~c~rs ('omf>i~nsafic~rr ct'r. Jateahiliq~ l3~ne~ts .Slx~e~ialistx .~inrr 1914
199 CHURCH STREET, NEW YORK, N.Y. 10007-1100
Phone: (212) 587-3976
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
POLICYHOLDER
POLICY NUMBER i CERTIFICATE NUMBER
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAME
FUND UNDER POLICY NO. 1 195 111-8 UNTIL 04/16/20q
FOR WORKERS' COMPENSATION UNDER THE
OPERATIONS IN THE STATE OF NEW YORK, EX ~
CERTIFICATE HOLD
.I L.~. _._....._-_---__ _ __
PERIOD D BY THIS C TI - E ^~ DATE -- 1
?' SUR TH T EW YORK STATE INSURANCE
ERIN HE EN IGATION OF THIS POLICYHOLDER
'O RS' COMP SATION LAW WITH RESPECT TO ALL
~S 1ND D BELOW.
IF SAID POLICY IS CANCELLED, OR CHANGED TO ~' IN SUCH MANNER AS TO AFFECT THIS
CERTIFICATE, 10 DAYS WRITTEN NO ICE OF SUC A LATIO ILL BE GIVEN TO THE CERTIFICATE HOLDER
ABOVE. NOTICE BY REGULAR M ESS SH SUFFICIENT COMPLIANCE WITH THIS PROVISION.
THE NEW YORK STATE INSURANCE T AS ME ANY LIABILfTY IN THE EVENT OF FAILURE TO GIVE
SUCH NOTICE.
THIS CERTIFICATE GOES I~eLY TO BU
THIS CERTIFICATE IS
COVERAGE UP Ti
COVERAGE FOR
THIS
AS R OF'fNFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
1 E H R. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
ICY.
NEW YORK STATE INSURANCE FUNC
!6.3
~~~~
,~-
DIRECTOR, INSURANCE FUND UNDERWRITING
This certificate can be validated on our web site at~https://www.nysit.com/CerUCertval.asp
VALIDATION NUMBER: 371850814
-9-
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION
GROUP SELF-INSURANCE .
la. Legal Name and Address of Business Participating~inaGroup
Setf-Insurance (Use Street Address Only)
"la"
le. NYS Unemployment Insurance Employer Registration Number of
Business referenced in box "la"
16. Effective Date of Membership in the Group
lc. The Proprietor, Partners or Executive Officers are
^ included (only check box If all partners/officers included)
O aU excluded or certain partners/officers exciaded
2. Name and Address of the Entity Requesting Proof of Coverage (Entity
Being Listed as Certificate Holder)
lf. Federal ]
Box "la"
of Ba~tess reterenced in
This certifies that the business referenced " a" ' omp with the mandatory coverage requirements of the
New York State Workers' Compensation Law as a of the Group Self-Insurer listed above 'n box " 3"
and participation in such group self-insurance is force. Group Self-Insurer's Administrator will send this Certificate
of Participation to the entity listed as the certift holder in box "2".
The Group Self-Insurer's Administra a certificate holder within 10 days IF the membership of the
participant listed in box~~" is ternlina ese ces may be sent by regular mail.) Otherwise, this Certificate is valid for
a maximum of one ~p~` fioi~he date ed by a group self-insurer.
If this certificate is ` rdi~o the above guidelines and the business referenced in box "la"continues to be
named on a permit, lic r contra 'slued by the certificate holder, the business must provide the certificate holder either
with a new certificate or other autho 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:
Certified by:
Title:
(Print name of authorized reprosentative of the Group Self-Insurer)
(sue) (D~e)
Telephone Number:
GSI-105.2 (2-02)
-11-
STATE &
MUNICIPAL
AGENCY
COMPLIANCE
WITH
§ 125 General
Municipal Law
November 3, 2003
ROBERT R. SNASHALL
CHAIRMAN
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
20 PARK STREET
ALBANY, NY 12207
June 1, 1999
To all Code Enforcement Officials, Building Departments and Municipal Entities:
nos ~oarctr ~~toYS M-o sEnvEs
r~oPr.E wRti oisAeiur~ES wrrHOUT
otscRn~tnaArwrr.
Effective January 18, 1999, Section 125 of the General Municipal Law requires that any individual applying for a building
permit must prove to the building department that he/she is in compliance with the mandatory coverage provisions of the
Workers' Compensation Law before the building permit is issued. _
General Background
Under Section 57 of the Workers' Compensation Law, businesses listed as the general contractors on building permits are
required to submit proof of compliance with the mandatory coverage provisions of the Workers' Compensation Law to the
building department before a building permit is issued. Section 125 of the General Municipal Law is specifically targeted at
ensuring that all applicants who list themselves as the general contractors on the building permit arc incompliance with the
mandatory coverage provisions of the Workers' Compensation Law.
For homeowner applicants, enclosed is a copy of the new form BP-1(3/'99) Affidavit of Exemption to Show Specific Proof
of Workers' Compensation Insurance Coverage fora 1, 2, 3 or 4 Family, Owner-occupied Residence. The law requires
homeowners to provide proof of workers' compensation compliance when applying for a building permit. If the homeowner
gaalifies for an exemption, the; homeowner must complete this form and file it with the local building department.
Implementing Section 125 of the General Municipal Law
1. General Contractors and Basiness Owners
Basinesses listed as the general contractors on building permits, must prove that they are in compliance with Section
57 of the Workers' Compensation Law (WCL) by producing ONE of the following forms indicating that they are:
+ insured (C-1052 or U 263 -the business' insurance carrier will send this form to the building departzent upon
the business' request),
+ self-insured (SI-12 -- the business calls the Board's Self-Lrsurance Office at (518) 402-0247 or •
+ are exempt (C-105.21- forms obtained from Workers' Compensation Board offices -copy attached
under the mandatory coverage provisions of the WCL. Any residence that is not a 1, 2, 3 or 4 Family, Owner-oo~upied
Residence is considerod a business (income or potential income property) and must prove compliance by filing one of
the above forms. (Please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!)
2.Owner-occupied Residences
Homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence, must file form BP-1(3/99) when applying for a
building permit when they are:
+ listed as the general contractor on the building permit, and the homeowner.
a is performing aU the work for which the building permit was issued him/hetself,
+ 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 then homeowner perforrir such work, or
-1-
Affidavit of Exemption to Show Specific Proof of Workers'., Compensation Insurance
Coverage fora 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):
^ I am performing all the work for which the building permit was issued.
^ 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.
^ 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 )
Property Address that requires the building permit:
BP-1 (3/99) _3_
o. -•- -o
Sworn to before me this day of
(County Clerk or Notary Public)
p. _.~ • •O
STATE &
MUNICIPAL
AGENCY
COMPLIANCE
WITH
§220 Subd. 8 DBL
November 3, 2003
Section 220 Subd. 8 --Restriction on Issue of Permits and the Entering of Contracts Unless
Disability Benefits Is Secured
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-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 Nit
B) Either the DB-120.1 -- Certificate of Disability Benefits Insurance OR the DB-820/829
Certificate/Cancellation of Insurance (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 Boazd's Enforcement Unit in the neazest 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 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-
Workers' Compensation Board); OR
NYS wce NYS wce
14Y3 WCB NYS WCB NYS W1.8 VYCJD8t00nOt
107 NYS WCB
wr~08taonot
141fS WC8 NYS WCB
tntc+oetoonot NYS WCB
tnrrr0ettanot wt'JO81o6not
1684691st
NYS WCB
WRJO8t00/tot
100 grosdwy wa08t00not
State Office tnrGOetaonot
111 Livinpstan Delaware 220 Rabro tNGDataonOt 215 W. 12bth 41 North Aw. wcioetoonot NYS WCB
AAernrtda Bw'Idotp Sl Aw. Otive 17b Fttgon St. Division St. 3rd Floor 130 AAain St. wrr09toatot
ALBANY 44 Hawley Street 22nd Fbor BUFFALO SttiM 100 Aw. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 Junes SL
12241 BINGHAMTON BROOKLYN 14202 HAUpPAUGE HEMPSTEAD NEW YORK 10586 1,432 14814 SYRACUSE
(888)750- ,390, ,1201 (866)2„- ,17e6 11550 ,0027 (866)746- (600)677- (b88)2„- ,3203
5157 (866)8023604 (800) 877-1373 0645 (888) 881 5354 (888)805-3530 (800) 877-1373 0552 1373 0844 (86B) 802.3730
fatdt (5,8) Fatdt (B07) Fault (718) Fatdt (716) Fats (831) Fatdt (516) FuaR (212) FuoY (914) FaxB (718) Fatah (585) FaxAt (315) 423-
473-9166 721.8324 8026642 842-2132 952-7986 560-7807 316-9183 .788-5793 291-7248 2388351
T~- 2938
Affidavit For New York Entities And Any Out Of State Entities wltn lvo employees, I pat Ivew YorK
State Workers' Compensation~Aid/Or Disability Benefits Insurance Coverage Is Not Required
(/ncomplete forms wiU be returned -Please contact an adorney If you have any questions regarding phis form.)
**TJiis form cannot be used to waive the workers' compensation riglets or obligations of arty party inc/uding 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. lncomnlete forms will be returned.
Please note: This statement must be notarized alad 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 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)
fora permit/license%ontract
State of
County of
ss.:
(applicant's name) being duly sworn, deposes and says:
1. I am the (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
name), a
The Federal
I affirm
number is
3. That the above named business is applying fora (type of permit/ license%ontract
applying for) from (governmentalentity issuing the permit/ license%ontract).
3a) {Optional - Location of where work will be performed in New York State
from to (dates necessary
to complete work associated with permit/licerrse%ontract). 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.):
^ 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).
^ 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 attoeh separate sheet,vtth a Use ojaU the partners mamas and also with the atgnatures ojall the partners)
^ 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).
WC/DB 100 (12/03) {Replaces C-105.21 Form} -3- (Over)
NYS wc6 NYS wc6
NYS WCB NYS WCB NYS WCB wr,+0etoonot NYS WCB NYS WCB NYS WCB wttmetoonot
vvcr0attanot tnrc+oetaonot wrdpptoonot 107 wroetoonot NYS WCB vur+oetoonat wc~oetoonot 1688 91st NYS WCB
100 BroWway Stale Olfice 111 LiNnpston Delaware 220 Rabro tnr~0etoonm 215 W. 125th 41 North Aw. vvcaoetoatot NYS WCB
Msntatds Buildkp St Aw. Drive 175 Fulton St Division SL 3rd Floor 130 AAain St. tnrc~0etoatot
ALBANY 44 HawNy Street 22nd Floor BUFFALO Suite 100 Aw. 3rd Floor PEEKSKILL QUEENS ROCHESTER 935 Jarnss St.
12241 BIN(3HAMfON SROOIO_YN 14202 HAUPPAUGE HEMPSTEAD NEW YORK 10566 11432 14614 SYRACUSE
(666)750- ,390, 11201 (e66)2„- 11788 11sso ,0027 (e66)746- (800)677- (886)211- ,3203
5157 (866) 802.96W (800) 877-1373 0645 (866)881.6354 (80805.3630 (800) 577-1373 0552 1373 0641 (866) 802730
Fab1(518) Fatah (807) Faz3 p16) Fatdr p,e) Fatd (631) Fatdt (518) Fatah (212) Fatdr (914) F~dl (718) Fatdt (585) FaxM (3,5) 423-
(tncompide forms wiU be rdurned -Please contact an attorney ijyou have any questions regarding
**T/iis jorn: cat:not be used to waive tl~e workers' compensation rig/its or obligations ojany 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-101 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)
fora permit/license%ontract
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
~) The Federal Employer Identification Number of the business (or -the Social Security
Number of the business owner) is The Nei~v 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 and my home telephone
number is (~
3. That the above named business is applying for a
applying for) from
3a) (Optional - Location of where work
(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/licenseJcontract). The estimated dollar amount of project is
f
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-101 (12/03) {Replaces C-105.21 Form} _S_ (Over)
. ~ STATE OF NEW YORK THIS AGENCY EMPLOYS AND SERVES
WORKERS' COMPENSATION BOARD 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 OPERATIONS EGIN ON OR ABOUT:
DISABILRY BENEFRS CARRIER (If more than one, list all) NYS UNEM NT U CE PLOYER'S REG. NO.
Applleatlon is heroby made to the CARRIER for a Certiffate of Compltanw with the Disabilky
Date Signed BY
(Signature of owner, pa
Tsl. No:. (_, Title Law.
authorized offlc~
-
PART 2. TO BE COMPI
CERTIFICATE OF COM
This is to certify that the above employer is insured wkh
and that the policy covers: • a. ^ ALL of the EMPL
• b. ^ ONLY the following
BENEFITS LAW
~nderYork Disability Benefits Law.
PLOY S employees:
Deb Signed _
( nature of carrier's authorized reprosentative (currency on file with DB Bureau))
Tel. No:. (_,
MMPORTANT: H BO)f'a'' C Meil tt directly t0 the employer.
k Box •b" is s certlfl NO COMPLETE for purposes of Section 220, subd. 8 of the Disability Benefits Law. k must be mailed for
completion to the Workers' Com lion Board, Disability Benefits Bureau, 100 Broadway Menands, Albany, NY 12241-0005.
PART 3. TO BE COM~ED BY WORKERS' COMPENSATION BOARD (Ony M box "b" of Part 2 has been checked)
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
There is on file with tho Workero' Compensation Board, Certlflesb of Insurance indieatlnp that the above•namsd employer has complied with the Disability Benefits
Law with rospect to all of his/Frsr employees.
DISABILITY BENEFITS BUREAU
Date Signed
Tei. No:. () Title
DB-120.1 (4-99) -~-
DB-155 (1/98)
-9-
4
~, - ~ ,.~.~, ,;= STATE OF NEW YORK
' WORKERS' COMPENSATION BOARD
°I ~"~`'~ ~~ 20 PARK STREET
- !i
,,~ ~ ALBANY, NEW YORK 12207
~ ~~~
Frr_istuR.-
ELIOT SPITZER
GOVERNOR
Dear Government Official:
DONNAFERRARA
CHAIR
August 1, 2007
Workers' Compensation Law ("WCL") Sections 57 and 220(8) 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.
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 WCL Sections 57 and 220(8), including the revised
forms that should be used immediately to carry out the WCL. 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 WCL 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 WCL Sections 57 and 220(8) is a critical component of
encouraging business compliance.
Also enclosed is a copy of General Municipal Law Section 125 that requires ALL applicants to provide proof
of workers' compensation compliance when applying for a Building Permit.
Please note that the old Form C-105.21 became obsolete as of December 1, 2003, and Form WC/DB-101
affidavit for out-of--state businesses with employees working in New York State will become obsolete on
September 9, 2007. This package contains extra copies of the new Form WC/DB-100, which replaces Form C-
105.21. To be valid, Form WC/DB-100 must be notarized and also stamped as received by the NYS
Workers' Compensation Board. An extra copy of Form BP-1 is also included. Form WC/DB-100 and Form
BP-1 are the only two 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 (9-07) is effective September 1, 2007. 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 WCL. 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.
Donna Ferrara
Chair