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1987/2007 (15)' STATE & MUNICIPAL AGENCY REQUIREMENTS UNDER GENERAL MUNICIPAL LAW §125 & wcL §s~ & §zzo FOR WORKERS' COMPENSATION AND DISABILITY BENEFITS Please call Steve Carbone at (518) 486-6307 or a-mail Steve at steve.carbonet'a~wcb.state.ny.us if you have any questions. WYS Workers' Compensation Board's Official Website: www.wcb.state.ny.us September 9, 2007 ELIOT SPITZER GOVERNOR DONNA FERRARA August 1, 2007 Dear Government Official: 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 ACO1zD 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 deparhnents 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. STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY, NEW YORK 12207 Donna Ferrara Chair -3- ~' WORKERS' COMPENSATION LAW §57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, boazd, 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, boazd, 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. WORKERS' COMPENSATION LAW (Disability Benefits) §220. 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, boazd, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, boazd, 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 cazrier 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. -5- STATE & MUNICIPAL AGENCY COMPLIANCE WITH WCL §57 September 9, 2007 -7- Section 57 -- Restriction on Issue of Permits and the Entering of Contracts Unless Compensation Is Secured Section 57 of the Workers' Compensation Law ("WCL") requires the heads of all State and municipal entities, 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 workers' compensation insurance coverage. To comply with coverage provisions of the WCL, businesses must: A) be legally exempt from obtaining workers' compensation insurance coverage; or B) obtain such coverage from insurance carriers; or C) be aBoard-approved self-insured employer or participate in an authorized group self-insurance plan. To assist State and municipal entities in enforcing WCL Section 57, businesses requesting permits or seeking to enter into contracts MUST provide ONE of the following forms to the government entity issuing the permit or entering into a contract: A) WC/DB-100 (9/07), Affidavit For New York Entities With No Employees And Certain Out Of State Entities, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required; (Affidavits must be stamped as received by the NYS Workers' Compensation Board) Form WC/DB-100 is available on the Board's website, www.wcb.state.ny.us. under the heading "Common Forms. It may also be obtained by writing or visiting any District Office of the Workers' Compensation Board. OR B) C-105.2 (9/07) -- Certificate of Workers' Compensation Insurance (the business's insurance carrier will send this form to the government entity upon request) PLEASE NOTE: The State Insurance Fund provides its own version of this form, the U-26.3; OR C) SI-12 -- Certificate of Workers' Compensation Self-Insurance (the business calls the Board's Self-Insurance Office at S18-402-0247), OR GSI-105.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance (the business's Group Self-Insurance Administrator will send this form to the government entity upon request). (Please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!) Government Officials Local Contacts with the NYS Workers' Compensation Board Government Officials should call the Workers' Compensation Board's Enforcement Unit in the nearest district office to notify them of anon-compliant business: Albany Binghamton Brooklyn Buffalo Hauppauge Hempstead Manhattan Peekskill Queens Rochester Syracuse (212)932-7576 (914) 788-5804 (718) 523-8409 (585)238-8335 (315) 423-1141 (518) 486-3349 (607)721-8334 (718) 802-6870 (716) 842-2056 (631) 952-6698 (516) 560-7742 Please call the Bureau of Compliance at (518) 486-6307 with any general questions regarding Section 57 of the Workers' Compensation Law. -9- uvs vMCe yy4et,waot !00 eaodoial ~sa~a l888~ 750 515' Faa~ ('SiA] *~w,~ wGOr+w+a ___ wrawCS wNpNanw irraweo ~~ rm~w~ Ewa ~w~au~ .u+. tuw NY6rvCa .wonww, ~w~ .wwnKnat ~eb~!!an ~ravNC:o i enrswee ! etw.o+v stAt,p 1ti Uatpoon woo~+wno~ K i+tr7 OolaYrna nOpi°'O ~ # ~M . ~ H Nate OMdoe ft. Nw, ~d Flow wrmara+ 190 4a~~ Se w.r,+,~aw. w3S ~a~w !t N F1~oIMY l~taM ~~ ~" ~ ~ "'~x M MGt~a7aND iN ftoor 1~NfM~ T6l14g1i OUE8N9 NtOChEfTEA S ~U9E w~.w+on ewai~ru .~~ r, , ~ „ew a06~ ~ +oaa[ (8001 dJT- ~oetw t8~ 718- I (~ d7T- 2st- (~) +~ese)soa• ~ ! ~- ~~ X21 f- ' ~~~ 3690 375tt I fatR (a1t~ Fasd (S18'- Fad (YfZ1 1 7 Fsxtl X18) ' 200E~ ~ it Fad f8Q'[} Ftei/ (718) Feat (Ta6} }dp ~t fD i4 7~'S 238-e~~ _ - l . - trs.atea 7zt.aNS~ aoz-atwts arzafeb ~~ And Certain Out Ot Slate Entities, That I+fewr Atfldt~vit Far New York Entftiees With No ~mployee~s _ York State Workers' Com ~~ ~s.M.i~w~ ~,g~~~~Coverage !s Nit Re~qui~ed necsult t6~ i~ s twors stlldsrlt. ewtplo7es! of tie Werkrr:' Cota-e*sstient Bwrd ssaeNn •srbt ^ppNrsntr io answorias gnettloa! pfiou# tbu rvrtn. *•7Trlrfwm q~aaol be ~ m.NOafer Nirs tronters` oontptattoa~~t r~Vkb o,r ab~aAloas ojatrp Parry •• Itcant may we this AII'xlawit Oi~TL.Y to aho~r a government entity that Nenv YorJx State specil:,~c warkcss' The app ' nee this farm tv show either vtErer compensation aadlor d'tsabiliity benofits insuranoa is oat required. Tbc spplica~t may businesses or those busineaus' insurance curies that. such in:an'estioe is scot rogtriired. applidnt mast wither fits oe tunil this coaopkted form to fhe eioseat hlew Yuck State Workers' CotttpeAtsHaat ward uft'~c5t at the t~ wnr'ber ar address listed eo me top of ttds tb~ae ieioeal+oletp Jonas will bs •~"'•••''~. t11V4TA]MPI~D. ^of ^od 7'flcN sent to lx, as rCCdved by We New York Stan Workers' IPteaac ^ofie:'t'h4 sht~entsttt ~~.~$t£T ~.°.l~ ~ ~msat aiYicFs4 one tatr wirer the dsie stratpsd ss rr~cetvtn by Conrpeersadate H~otK+tl. Thb afllefavit rr net ibt aoaep 67 t ~e R'o~rkers' Coatpeasation beard. R ,. vin t v ~-1rb141Rf R't'$D FORM W 8160. rift Workers' Cosnpanaaltan Hoard will slantp tfiis .trletth S 6aetaese days. 1"least pfow'ide a eaP7 ~(or the ori~inai, if ores as rtoetved~ rrtant it to yet by ellber aatll or raft ~, t +att [ram wkk6 Yoe ace recltr~trag a Rcrmtt, regairsd by tkc Hovernnteot sntity'j at this stainpsd tarot to tba ga+ne~ hY license or esatrsbet. ~ q~,kppiicatios of (Bairiauses Tlame astd AdR1*~eas} Coca pettttltllioenselcaatract S'dttr of ) .a.: Cotent~ of _ _ __ . _~_ ~ j . (etzne''a xaAte} bciu; duly avvarn, 'es and sot's: Ia) I atr, the (part~aut) wiih the attc~va-Mnd:rad bttsineas, elan i'na~ of byasi~ts-s.~. 8 ~h'° o~~ ~~ f°O~~ ~~ ~). '~~o telesphar-e ~nber aF th~c b+as~nass is . '1"he Fe~a! Etstp7o~t* Idettd~io•timt i'Jvnlber of the buss (gar the Social Security -- - . I affiesn that duo to mY pasidon with thu above-named Nusnbar of the- twos fiw~) ~ to tnskc thmt a#it-~dttv'it. tsrf~atiCat aed tY rnd ~ ~ ~~ tclCpboe-e nucnbec is bari>srsq I hawse the imt7avjodgrc, ~ ~ p~oQtal addrt~ f~'Pe gi t1~ t~ce~nsa/controer ~ the above nsattod bpi is ~Y~B ~ a (go~rNareata! sr~tp 8 ~ peratif! licr~stlc+~'artj. frrom to New Yts:k a Q~yt~ionrs- ... Lacatwoo of where wruk vrill bG paifortned &um zn (darea~ necxrrr~ry to caaplere ,I'he eeued dollar asnoatt ofpra}ecs is . } faork ersmeloted reltb peTstlD+Jf ~ ~ k iu ~Q~' 1~Q~~' ~1 CI~STAIIrT HIeW '1['OLtK STA'T'E SI~CIF'iC 4. Tbat flu above mated baaytes~a rmutan (to br al[giblb for a~ aptpl~lat rnnsr ba Wt711ti~RS` ~pSATION ~~ GriiBSAGl~ for tlu faBawie~ able w tratt~ilY ctxdc OD78 of the boowae from ~- 4i.x d lobar. ~,] 4:.) the basilstess is o+anaed by one indivWuai and is oat a coupondon. C>~er ttuaa tfie owner, flare are no cmpt~ayers, aY Jarred enspiayees, boaro~wed esuployees, pert-dstrE °~°Y~• 1°'p°id ralmt0eers (iaefudh+8 fsmity arembera) cc wbcorrtractor'S. ii wcl~~-100 (~-o~ (1> corm c-los.z~ } (o~-et -11- STATE OF NBW YORK OVO~~S' OOMPIrTi'SATIO~I 80AILD CER7'[FICATE OF NYS WORKERS' C01H1'F-NSATIOI~` FI~ISURA3~1C`E C~~~G~ la, E,egal Name A AddrCas of Tns+ared Nsc alrKt addrea ooly) I !h. B~rteaa Tskphoae F[amber of lnsnred lc. NYS Uoempbgtuest [osarytttce E,mpbyer ReRtstrrtlor Natsber of lamrad 1~1. Federal T3st yer ldea n Number of Insurod Work Location afTmrtrcd (Oulyreq+rlrrd~caoa~beiVa'' ar Soeisl Security N' 1~+rd ro oerr+riw ioeatioRS br New Yalt Shore, Liu, +~ p'-~'UP PoilcyJ 2. Name and Addr~al a<thc 6otity RequestindTroof of Corerate {BatBy BeisE LbRed as the CertiAcaEe Bolder) 7s. Naate of lAlari00C 3b. p~Ymnber ofetltity ksted or F.xectrtlve Oftfcers sec: 4~h' eYedt tws M Ul partrtt~fAncrA led.dcd} ed or pertain parWera-ofAoers eicladed. This tectiaes tier tlta i ~ ~mort uo&r the Nta York o>, the tTip~UR,A'IATION PAt;It e[ lie r this Ceriifkale of Utsuraace to tht! 7fre 1mr~rQ+~r Cartltr tvW or wtYhlir 3D days !F tlisra auvaogs fndlraoredw+dilsl 144b forirr 6 oP'P~ ~' ~ > ~ Pk+rt upes~c Q'.~c" aauned s petsnit, ~ceNe or orw ~~ basiaem reFertt~cad above in bmc "la" far workers' t1tN f~rs.Ne~-Yark(NY) mttri be llsfted aodcr [tcof 3A ~~, 'mac Iastatrtte t+atTior or its liocttsed ageatt vrlll send bolder m box "2'. r c~er ~lratderwf tlrhr l t) days lp apoll~cy rs caRcdt~d drrt ro +~+P'~3'm~ aIPU'eA+Etrnw dYcvt ~~ p~ sax+e11/tc pe11ry ar elrnorreats 1hs rntrn'ed f 'oae rha tarFaa ~9 ant tryngWlor ~) Odrenolu'' d~ ~ ~ °iQ~fdforanvs,>~r ~a- ~payerrmndlt~ep~~y~~~rtedbrb~nt"3c".~+ ri rJbe ~, ladict~lsd on Mils force, ii the bnataeaa coetiaues to he of tie w ~'P~a pow iaittal 6I- a eet~ttte ho4ler~lht iwsbeaa aomt prot+lie that oertilicste io18m` wlti s ttew errt~r oe osier nrlMrlced proof tW! tltt: bmlaraa l: eaaplyimC Nllh the assdatory Worieet~' Compata~oa T.rw. Under par~l<y o[ parjttq,l ~ l6st I stn ao strdio~aed repreaaabtive.e llctrnted adealt of tie i~sersncs carrier referenced above and tbst the trrrtcd in lots the t d depic~tetE at iltia ~. ~~ ' Ipe;utiwtad'euioiimd ieAae.~t+'a ie`orrd+~t o~rwsawa aRiar) Approval by: tsis~i ~- Tefapboae NumbeQ of arAhorixod r'~~ ol• Uoarttied agrmt of insortoce carrier: rlieir ficraraod s are aulltoru~ed la lar+te Fa.+a C-105.3_ hast+ra+rese' i'mMtera ~e N(I7' Please Nett: ~y lnsea~ carriers mid p~l~oriaed ro rrawt tt. G105.2 {9.07) www.wrbslatc,ny us 3 -13- ~ter+~'~ork St~.t~ Insur~-nce ~~= unc H~ordrrs ~,'~~c~atiwrl h lai.~ablftq~ 8cnc,J'r~s czal~sr~ .'~Incr ! i+l ~ ~~ ax~acK s~e~r. New carat. r~.Y. ~oaor-i Boa lrera~ ¢+~} see CEI~TIF~CATE OF 1NOR~.~RB' COEN~~Tt~N 1N:il1R~t1+1 Poucn~ux~a - -~.. i~i~F1C~TE I L ___ ~, , ._._ ... _.__ . pOiUCY NlAJ19E.P~ .. ~ ~#T~FMGATE N~~A~ER PER1~Db ~.,,. _ ~:. ~..~ ~.~__...... ... Tom. TFAS IS T~} ~RTd:Y THAT THE'P~'~tIC~HO~R FtM~ID IiND~ P01aGY NO. 1146111•B 1lNIT~ 4wl"f FiO~R WORKER' Ct7A+IF'EIT10l+I UiN TIC CiP~A14TJpNS Nl Tl~ STATE iyF N9~ lA0~i1lC. d= 614 POL~`~ ~ GIINGELI.~A. OF# ~! CeM~T1FIClt~'E. /0 QJIY$ WF11~+1 DOME. NCf11E7E EY P TFiE NE'W Yb~ ERAYf Ih1dtJRA1~lC~ $EJCM Ni?*~- ti"FIIB CE~TiFiC~~'t~' ti~0E5 ~ TMo~ ~~~ ~ cbwE~p v7 RY T~s ~? ED dYTNiE W YOPK 8tA7E iPL9UFiANC."E ON ~ TFgS f°C?'t.1C`-'FiO~U~ Fi I.r-~-" 1-YFtt~l R~'ECT TO u.,1 M Bfa1.bW. Ili S1J~CH iJfANNER AB TD J4FRdGT Tests IIr~J. fi£ t~fVEN TC1~ TFi~ CBF1?~1~IkT~ ~ICyE~Fi ~lPF1Gdht'F G~+l:tAWCE W R'H i~+AC)M1IlSAON, AIr1f LtA~dTY IN `dF~OE EY~Er>tX b~ ~,ru„Ur~ TO GiV~ ~Tqp Y ~AFID ~ HO RK~7`~ NOR R~3ll THl~ ~~ OdES F!O'i p11i~6+d1. EiCTEND OR AtwTERI!F~E NEW 1f~3RK ~'T~T~ IN~LIRf4NGE F ~~ 1»~~~ `ihla audlicd~e bD wdit#auad e1A ou* ~ ~ ~'tUt~+*J~w"w.r~I,,oo+r~VOeif~os~lisiF .~Ti~ ~L11: ~7t 8 -15- grll'!`6 Of NL'V~- YOltlK WORKB~S' COM!'SMSwZi09~t aOARp CRR1~~iC'A'~ ~F PAR1"fI~G'~'AQTiYO~n~F~II1~~ VN''~O~ ~(/''~p S' C~1~iP~NSA'TI4N ~~V~ ~+~ ~i~~1.T~V7+~~r+iJ. 1i~. >~ Ntme me ,-adrem ~f>lyd~es~ g,.etsiptNa*in'tk••v sst!•-~acor~e N+~e seee+a X~a~s OrA~ la 1~, ~tieeth~e D+~o eS Mrmbr+sWP ~ the Ge+.od . - 1l. i-sdie~ 2~'i~r hs~pelebse~ Pte~tees ~ d~gier s~ ~oae ~'!s" Q ladad~ ~' ebeclc ~aat K~~ pfu~'bd~ded) O ~0 ceded •r ~p ~ ~ds+dud /1 3. l~ss4c ua AYd~Ot'+m ~~ B++dRlr 8t ~a~ r~wraEs Lirord.iC> ~,~ iie I~os "1~' Re~C~allW. ~, ~, ist due 6roaora~ rc ~~ ~r Yot'Ic 91a~e'~'~ ~~ ~~,y~ ~Ipgd~oa~,wat ~,.6.~p~pu _ . ~ i~ ~e i ZUO ~~ ~`d~'A ~~ pp~t hoed is a ~ s a of •~ +~'' by If 1i~s oetr,(ta ~ ~ar4 a~ wi~i ~+ ++e+d ~' or ~ New Yr,Pd`~aale I~a~I~vs'' ~lnd~er pe~sWy a~f pet'~'~uT, r+tf~et+e~ tbit t! ~~:~ofll~t ~ $eifd 'b°~''s m box "3" ~ pmu~ ~ 1 s ~ ~vliT sand i~ix C~ ~~• W ~ ~ r~-~.awv ~,~'tl,~ Y8~ ~1~ ~~ ~-~W: ~e eobo.~e pad +~ rye ~raip~a r'~ ~ bQx 'ia" ra~e~s ~ be' ~rotda'. tlnr ~,n~st ~ ~ J~Idcr ~ill~ar Y'a+" at dies ~ S~~ Insurer ~t I am stn ~~ ~ ~ Ecrm,. re; b~s~ re'ea~ I~ bins "1~" h~ Ehn ~~$ ~ depiet~ed ~c~€fod bY= prr. „~.,,.rra~.+n.o•~.r~. ~r s.~a~•+s3 (~~p~ - i ~. .. .. ~~y • - T~ ~ 1 / ~~~~~ ~ ,~ 17- STATE & MUNICIPAL AGENCY COMPLIANCE WITH General Municipal Law §125 19 September 9, 2007 -19- NYS WCB NYS WCB NYS WCB nTa W(.tl wf:IDBtoWto7 NY8 WCB NYS WCB wc~oetoono~ 70 Broadway wcme~oonot State Office tn~cmeloa~ot 111 Livingston 107 p~~ vvc+De/oono~ NYS WCB NYS WCB wcme+oonot NYS WCB wc~oetoalo~ wtrroeroonoi 168-4891 t Msnanda Building SL e Ave i ~ O wGDBIOOMOt 215 W. 125th 41 North s Ave NYS WCB wcm ALBANY 44 HawNy Street 22nd Floor . BUFFALO r v Suks 100 175 Fulton Avs F . e~oo~o~ NYS WCB 12241 (866) 750- BINGHAMTON 13901 BROOKLYN 14202 HAUPPAUGE . HEMPSTEAD 3rd loor NEW YORK PEEKSKILL QUEE~ ROC ESTER wtr+oatoonoi 935 ,lames St 5157 F (866)8025G04 11201 (800)677-1373 (866) 211- 0645 11788 (888)881.5354 11550 (886)805 9630 10027 80 10586 (888) 74~ 11432 (~)B77- 14614 (868)211- . SYRACUSE 13203 ax# (518) 473 9166 Fatdt (607) 72 Fad! (718) Fa~dt (718) Fa~dt (631) . Fawtt (518)' ( 0)877-1373 Fault (212 t)ra52 ) 802.9730 . 1-0324 8026642 842-2132 952.7966 560 7807 ) Fax#t (914) Fault (718) F (585) Fes - 316-9183 7885793 291-7248 2~8~,r1 ~~) 423- 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 wiU be returned -Please contact an adorney ijyou have any questions regarding this form.) **Thu 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. Incomplete forms will be returned Please note: This statement must be notari2ed sod also have been st coned 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) for a State of County of pennit/license%ontract } 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 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 and my home telephone number is U 3. That the above named business is applying fora (type of permit/ license%ontract 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 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 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 ojaU the partners names and also with the signatures ojal! 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 WCB wrrnetoonot NYS WCB wcroetoonot NYS WCB wc~oatoonot NYS WCB waoetaonot 107 NYS WCB NY3 WCB NYS WCB DO Broadway M Stats Officx 111 Livingston Delaware wc+oatoonot 220 Rabro NYS WCB wc+oettanot NYS WCB vvc+oetoatot wceoBloawot 168-48 91st enands ALBANY Buildi n9 44 Hawley Street SL 22nd Floor Ave, BUFFALO Drive Suit 100 wtioatoonot 175 Fulton 215 W. 125tlt SL 41 North Division SL A~• 3rd Floor NYS WCB w<'roetoonot 1 NYS WCB 12241 (~) 7~' BINGHAMTON 13901 BROOKLYN 11201 14202 e FUUJPPAUGE Avs. HEMPSTEAD 3rd Floor NEW YORK PEEKSKILL 1 QUEENS 30 Main SL ROCHESTER >~ JameatSL 5157 Faak (518) (tt86) t102~804 FaxB (607) (800) 877-1373 P (8B6) 211- 0645 11766 (866)68145354 11550 (686) 805.9630 10027 (800) 877-1373 0588 (~) 746- 11432 (~ 73n- 14614 (8B6) 211- SYRACUSE 1 ~ 473-8186 7214!324 ortal(718) 802.8842. Fats/ (718) 842-2132 Fatdt (631) 952.79ti8 Fato1(51B) 560.7807.. Portal(212) 318Ataa 0552 Fax* (914) mn_cso FatoY p18) ..... ._ Fexrk 585 ( ) (~) ~~ Fatal (3151a~z (/ncompleteforms w1Ube returned- Please contact an aYlorneylyou have air y questions regarding this jornc) **T/iis form cannot be used to waive the workers' compensation rights 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 notari _ed and also have been staff 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.. permit/license%ntract (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 (_~ 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 permit/ license%ontract). 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 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 1 a. Legal Name and address of Insured (LJse street address only) I 1 b. 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 limited to certain locations in New York State, i.e. a Wrap-Up Policy) Social Security t 2. Name and Address of the Entity Requesting Proof of 13a. Name of Insurance Coverage (Entity Being Listed as the Certificate Holder) 3b. Po umber of entity listed of Insured or or Executive Officers are: (Only check box if all partnels/officers included) :d or certain partners/officers excluded. is: (Definition of Demolition on Reverse) excluded. This certifies that the insurance carrier indicaf bove " insures the business referenced above in box "la" for workers' compensation under the Ne ork State Workers' nsation . (To use this form, New York (NIA must be listed under Item 3A on the INFO N PAGE of th r 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 ofpremiums that cancel the policy or eliminate the insured from the f (These noti m be sent b re coverage i n this Certi 1 ay y gular mail.) Otherwise, this Certifu;are is valid for a maximum of one yea ter this m is approve the insurance carrier or its !!tensed agent: Plesse : Upon the license o State Workers' Ca Under penalty of above and that th Approved by: Approved by: Title: or rs' compensation policy indicated on this form, if the business continues to be named on a permit, older, the business must provide that certificate holder with a new Certificate of Workers' ed proof that the business is complying with the mandatory coverage requirements of the New York that I am an authorized representative or licensed agent of the insurance carrier referenced has the coverage as depicted on this form. (Print name of authorized representative or licensed agent of insurance carrier) (Signature) (Date) 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. Z form. authorized to issue it. C-105.2 (12-03) -~- Insurance brokers are NOT u~°~~'r~ ~-'°m1k~nrniivn ct'r. DLenhili~~~ 134rne~its .Slxrc~alist~' ,~ir~t~ 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 . CERTIFICATE HOLD i PERIOD D BY THIS ~ THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED FUND UNDER POLICY NO. 1 195 111-B UNTIL 04/16/20 FOR WORKERS' COMPENSATION UNDER THE~YC OPERATIONS IN THE STATE OF NEW YORK, EX AS DATE SUR TH Th EW YORK STATE INSURANCE HE EN IGATION OF THIS POLICYHOLDER RS' COMP SATION LAW WITH RESPECT TO ALL D BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED TO IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 GAYS W RIT'TEN NO ICE OF SU A LATI ILL BE GIVEN TO THE CERTIFICATE HOLOER ABOVE. NOTICE BY REGULAR M ES3 SH SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE T AS ME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. !6.3 THIS CERTIFICATE DOES LY TO BUIL MOLITION. L C EFF E ~~~ ~ DIRECTOR, INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at~https://www.nysit.com/cert/certval.asp VALIDATION NUMBER: 371850814 . -9- THIS CERTIFICATE IS ISSUE AS R O NFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UP THE CER I E k R. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE FOR D BY TH OLICY. THiS PO I NEW YORK STATE INSURANCE FUNC STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION GROUP SELF-INSURANCE . la. Legal Name and Address of Business Participating ~fn~aC:roup Self-Insurance ([1se Street Address Only) lb. Effective Date of Membership in the Group Ic. The Proprietor, Partners or Executive ORcers are O incladed (oNy check boz if all partners/oflicers Included) ^ all excluded or certain partners/ofTcers e:clnded 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as Certificate Holder) le. NYS Unemployment Insurance Employer Registration Number of Business referenced In box "la" lf. Federal Employer Boz "la" of Bu~ress referenced in This certifies that the business referenced " a" i mp vinth the mandatory coverage requirements of the New York State Workers' Compensation Law as at of the Group Self-Insurer listed above ?a 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 ceraf- holder in box "2". The Group Self-Insurers Adminis a certificate holder within 10 days IF the membership of the participant listed in box ~~" is~ termina ese ces maybe sent by regulaz mail.) Otherwise, this Certificate is valid for a maximum of one ~~~Mio131~he date ed by a group self-insurer. If this cert~cate is ord to the above guidelines and the business referenced in boz "1 a"continues to be named on a permit, lic r contra 's ed 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: Telephone Number: GSI-105.2 (2-02) (Print name of authorized representative of the Group Self-insurer) (sue) (Hate) -11- STATE & MUNICIPAL AGENCY COMPLIANCE WITH § 125 General Municipal Law November 3, 2003 ROBERT R. SIVASNALL 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: PEOPLEPEOPLE WITH DISA8IUTIE3 D{p j~~p~s DISCRIMINATION. 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 roquic+od 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 are in compliancx 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 Ezemption to Show Spedfie Proof of Worketa' Compensation Insurance Coverage fora 1, Z, 3 or 4 Family, Owner-occupied Residence. The law requires homeowners to provide proof of workers' compensation compliance when applying for a building permit. Tf the homeowner gaalifies for an ezemption, 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 Business Owners Businesses i(isted as the general contractors on baIIding permits, must prove that they are is compliance witb 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 departrent upon the business' request), + self-insured (SI-12 -the business calls the Board's Self-Insurance 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-occupied Residence is considenad a business (income or potential income p~+operty) and must prove compliance by filing one of the above forms. (Please note: ACORD forms are NOT acceptable proof of workers' compensation coveragel) Z.Owner-occupied Residences Homeowners of a 1, 2, 3 or 4 Family, 9~~er-occur 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 all the work for which the building permit was issued him/herself, ¢ iss cot hiring. paying or compensating in any way. the individual(s) that iis(are) performing all the work for which the building permit was issued or helping the homeowner perform 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(aze) 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 i 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 govenKUnent 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) (Homeowner's Name Printed ) Home Telephone Number Property Address that requires the building permit: BP-1 (3/99) _ 3 STATE & MUNICIPAL AGENCY COMPLIANCE WITH §220 Subd. 8 DBL November 3, 2`003 . 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 Coveraee Is Not 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 Iiow a Business Requests a DB-155 Form Businesses should call the Workers' Compensation Boazd'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 rws wce NYS wce NYS WCS Wd0Ef00not NYS WCB NYS WCB NYS WCB vurdoetoonot uvaoettttvttn vvcmettwnot tnrcmetaonot 107 wtroetoonot NYS WCB wroettwnot wc~petaonot 1888 91st NYS WCB 100 Broadway Stste Office 111 Livlnpston Delaware 220 Rabro YYCJDB1tIDHOt 215 W. 125th 41 NoAh Aw. WCA9t00/tot NYS WCB Msnands Buildrt9 SL Aw. Driw 175 Fulton St. Division St. 3rd Floor 130 Mein SL wc~eoettwnot ALBANI' 44 Hawley 8fteet 22nd Fbor BUFFALO StAle 100 Aw. 3rd Floor PEEICSIOLL QUEENS ROCHESTER 935 James SL 12241 81NGHAMTON BRt>OKLYN 14202 HAUPPAUOE HEMPSTEAD NEW YORK 10506 11432 14814 SYRACUSE (886)750- 13901 11201 (866)211- 11788 11550 ttxl27 (866)746- (600)877- (886)211- 13203 5157 (866) 8025604 (800) 877-1373 0645 (BBB)881-6354 (688) 805.3830 (800) 877-1373 0552 1373 0644 (B8B) 8025730 FawM (518) Fatdt (607) Fault (71 B) Fsndt (716) Ftedt (831) Fault (516) Fawn (212) Fatdt (914) Fault (718) Fault (585) Few (315) 423- 473-9166 721.8324 802~68~42 842-2132 952-7986 560-7807 316.9183 .7885793 291-7248 238.8351 2938 Aff idavit For N ew York Entities A nd Anv Out Of State Entities With Nn F mnlnvPPC That NG>t1A/ VnrL ------ - --- - ---~ --- -- ----- -•----•-- - ---•- --- -• •t-•-~---~ ............ ~ vtr~ State Workers' Compensation~A~rd/Or Disability Benefits Insurance Coverage Is Not Required (tncanplete forms wiU be returned -Please rbntaa an attorney ijyou have any questions regarding fhis form.) **Tl:is form cans:ot be used to waive t/ee workers' compensation rights or obligatio~:s 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. lncomnlete forms will be returned. Please note: This statement must be notat7!zed 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 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 aze requesting a permit, license or contract. In the Application of (Business Name and Address) for a State of County of permit/licenseh:ontract 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 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/ license%ontract applying for) from (governmental entity issuing thepermit/ licenselcontract). 3a) {Optional - Location of where work will be performed in New York State from to (dates necessary to complete work associated with permit/licenselcontract). The estimated dollar amour 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 employces, part-time employees, subcontractors or unpaid volunteers (including family members). ^ 4b.) the business is a partnership under the laws of New York State aad is not a corporation. Other than the partners, there are no employees, leased employces, borrowed employces, part-time employces, subcontractors or unpaid voluntcers (including family members). (Must attach separate sheet >nith a list ojall the parlnus names and also wkh the signatures ojall the partners) ^ 4cJ 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 employces, part-time employees, subcontractors or unpaid volunteers (including family members). WC/DB 100 (12/03) {Replaces C-105.21 Form} -3- (Over) NYS WCB wcostoavtot NYS WCB wc+0etaonot NY3 WCB wr~oetoonot NYS WCB wcroattwnot 107 NYS WCB NYS WCB NYS WCB NYS WCB tnr~oetoanot Broadway State Olfioe 111 Livinpetan Delaware wrd0atoonot 220 Rabro NYS WCB YYCJOBtOeMOt t~oatoonot 215 W. 125th tnraoBroonot 41 North 1686 91st Aw NYS WCB ~Asrtertda B~din9 M Hewlay Street St 22nd Floor Aw. BUFFALO Chive Suite 100 175 Fulton A St Oivieion SL . 3rd Floor WCJDBtooHOt 130 Mein St. NYS WCB wrroetoonot 12241 BINGHAMTON BROOKLYN 14202 HAUPPAUGE w. HEMPSTEAD 3rd Floor NEW YORK PEEKSKiLL 10556 QUEENS 11432 ROCHESTER 935 Jatnea SL (886)750- 8157 13901 (886)802.9604 11201 (800)877-1373 (866)211- 0645 11788 (888)BB1~8354 11550 (888)805-3830 10027 800 877 (868)746- (800)877- 14814 (886 1- SYRACUSE 13203 FaxB (518) Fatah (607) Fatdt (718) Fabl p16) Fabt (631) Fatah (516) ( ) -1373 Fab- (212) 0552 Fatd~ (914) 1373 Fab1 p18 F (868)802730 473-9166 7213324 802$642 842-2132 952.7986 SBQ7'enl a~as~ra eve .,., ) .,... ... able (585) --- -- Fatdt (315) 423- (tnconlptde forms wiU be returned - Please contact an attorney ijyou have any questions regarding this form) **T/iis jornt cat:not be used to waive the workers' compensation rig/rts 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. Ineomnlete forms will be returned Please note: This statement must be notarized and also have been stn ved 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 mai! 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.. permit/license%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 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 number is (_~ and my home telephone 3. That the above named business is applying fora (type of permid license%ontract applying for) from (governmental entity issuing the permit/ license%ontract). 3a) (Optional - Location of where work will be performed in New York State from _to _ (~~ necessary to complete work associated with permit/licenselcontract). The estimated dollar amount of pmject 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} (Over) -5- STATE OF NEW YORK WORKERS' COMPENSATION BOARD EMPLOYER'S APPLICATION FOR CERTIFICATE OF COMPLIANCE WITH DISABILITY BENEFITS LAW THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. 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 (Nome or Main Office) LOCATION OF OPERATIONS NAME UNDER WHICH BUSINESS IS CONDUCTED, IF DIFFERENT FROM ABOVE OPERATIONS EGIN ON OR ABOUT: DISABILITY BENEFITS CARRIER (If more than one, list all) NYS UNEM NT U CE PLOYER'S REG. NO. Application is heroby made to the CARRIER for a Cerflfleate of Compliance with the Disability BA ' Dais Signed ey (Signature of owner, pa Law. authorized offlcef PART 2. TO BE COMPLETE ISABIL EFITS CARRIER CERTIFICATE OF COMPLIA ITH I ITY BENEFITS LAW This is to certify that the above employer is insurod and that the policy coven: • a. ^ ALL of the EMPL N undee ork DlsabUHy Benefits Law. ' b. ^ ONLY the following dai ~ PLO ~ S employees: Oats Signed ( nature of carriers authorized representative (currently on file with DB Bureau)) •IMPORTANT: M Bwc "8" s Mail it directly to the employer. H Box'b" ~ s Via,: NO COMPLETE for purposes of Ssdion 220, subd. B of the Disability Benefits Law. K must be mailed for completion to the Workers' Comps Board, Disability Benefits Bureau, 100 Broadway Menands, Albany, NY 12241-0005. PART 3. TO BE COM D BY WORKERS' COMPENSATION BOARD (Only ff box "b" of Part 2 has been checked) STATE OF NEW YORK WORKERS' COMPENSATION BOARD Then is on file with the Workers' CompsnsaUon Board, Cerdfleab of Insuronu indiadng that the above•named employer has complied with the Disability Benefits Law with rospect to all of his/her employees. DISABILRY BENEFITS BUREAU Date Slgnsd Tel. No:. (__) Title DB-120.1 (4-99) -~' DB-155 (1/98) -9- STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY, NEW YORK-12207 ELIOT SPITZER GOVERNOR DONNAFERRARA CHAIR August 1, 2007 Dear Government Official: 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 z ,,; ~> ' f y ~ ~,~~!~.~' '` STATE OF NEW YORK `~ ~ ~~' WORKERS' COMPENSATION BOARD ~ = '`~~~~ ~.~ 20 PARK STREET pµ, ~ ) ALBANY, NEW YORK 12207 :, ELIOT SPITZER GOVERNOR September 9, 2007 To all Code Enforcement Officials, Building Departments and Municipal Entities: DONNAFERRARA Effective January 18, 1999, Section ]25 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 are in compliance with the mandatory coverage provisions of the Workers' Compensation Law. For homeowner applicants, enclosed is a copy of the new form BP-1 (9/07) Affidavit of Exemption to Show Specific Proof of Workers' Compensation 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 qualifies for an exemption, the homeowner must either complete this form and file it with the local building department; or the homeowner must complete the WC/DB-100 form, have that form stamped by the NYS Workers' Compensation Board and file it with the local building department. Implementing Section 125 of the General Municipal Law 1. General contractors and Business Owners Businesses 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 (Form C-105.2 or U-26.3 -the business' insurance carrier will send this form to the building department upon the business' request) All private carriers and their licensed insurance agents are authorized to issue the form C-105.2 as their Certificate of NYS Workers' Comp Insurance. The State Insurance Fund uses the U-26.3 form as its Certificate of NYS Workers' Compensation Insurance, - self-insured (Form SI-12 -- Certificate of Workers' Compensation Self-Insurance (the business calls the Board's Self-Insurance Office at 518-402-0247), OR Form GSI- 105.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance) (the business's Group Self-Insurance Administrator will send this form to the government entity upon request). - exempt (Form WC/DB-100 =forms obtained from Workers' Compensation Board offices), {Form WC/DB-100 is also available on the Board's website, www.wcb.state.ny.us. under the heading "Common Forms. "f under the mandatory coverage provisions of the WCL. Any residence that is not a 1, 2, 3, or 4 Fainily~,lOwner- occupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. (Please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!) -21 Afiid»vit of Exempt~uo to Show Specific Froof of'Workers' Cvmpeasation Insurance Coverage fora 1, 2, 3 ar 4 Fam~~y, O~-++ner-occupied Residence ••Tli1s jorrir caawoi be psed la wilv~e ~e Kwr~err' ca+gp~aneltoa -i~e or abugatioaa oj~rr+~ parry. • • Under penalty of pecjury, I certify they 1 am tlye owner of the 1, 2, 3 ar 4 family, a~rrncr-occupied residence (including candarniuai~ns} listed on the buiWiDg peraut that I am applying for, and I sm not required to sfiroo~x ,nsaranoe c~o~verage for such residence bocause (please check the specific proof of workers' compensation . appropriate box): ^ I am performing all the work for which the building permit was issued. ^ 1 am not hiring, paym8 ar campcnsating in eat' way. the individual(s) that is(are) pcrf`ormir~g ail the work for which tht building permit was issued ar holping me perform such work. Ii that is ctrrrerrtly in effxt and covers the i~Pem' listul on the ~] I have a homeowner's insurance po cy attached building punnit AND am hiring ar perying iadividuafs a total of less tht+n 40 itiours per wok (a~egate hours far all paid individuals orr the jobsita} for vwltich the building permit was rued. I also agree to either: ~ ~ ~~de apple proof of that coverage an • ~'~'~ ~°~7e~ ~~~ ~~ ~Se n Board to the government cutity issuing the forms. apErrrove+d by the Chair aftha N"Y'~ Wocleers' Cautpe~tiO r week (~~5~ haYU~s far building~pea~rt if I new tea hire ar part' individuals a total of 4U hntrrs near triore pe ~ ~, appropriate, f lc a all paid individuals o~n the jaboktic} 'For work indicated on the building pes'mi~ 'WGDB-1flU escempdoa form; i}it • have the cofactor, performrug the work an the 1, 2, 3 or 4 f.arnily, ©woas~-orenpied residence Itsted on the buildingpernut #h~ I am applying for, pmot+ide appropristt proof of ('includmg condotainitg~) ' ovecl by the Chair worka:rs' compensation coverage or proafofclctmption fman that. coverage ott farms appr if the ct of the IJYS W orkexs' Goan f-enasdan How to tine ~t ~ ~ ~ ~"mt P~'~ takes a total of 4t} hotus or more per wade f a h°+~ss fot ali paid individuals oa the jv~ite} far ~w~ork indiratod on the building permit. (Date Signc~ (SignE}ture of Horneownez) (Ilomoowaa's I'dame PriN~} Properly ~-$ that requires the btrild'eng permit: bdoe ^at4rlaed, tbi Fawn BRT serves au as ezemption toe' both ~wo~rl+OaS~' e+raapenuaa~ Ao~d disability benclfts doe c~a!f'a;e- gP-1(~-07) rtY-~VCB 23 - 23 - 1-Iome Tei~ Number .STATE & MUNICIPAL AGENCY COMPLIANCE WITH WCL §220 (8) Disability Benefits 25' September 9,,21107 Section 220 (8) -- Restriction on Issue of Permits and the Entering of Contracts Unless Disability Benefits Coverage Is Secured Section 220 (8) of the Workers' Compensaiton Law (WCL) regarding disability benefits 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 WCL regarding disability benefits, 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 WCL Section 220 (8), 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 With No Employees And Certain Out Of State Entities, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required; (Affidavits must be stamped as received by the NYS Workers' Compensation Board) Form WC/DB-100 is available on the Board's website, www wcb.state.ny.us. under the heading "Common Forms. " It may also be obtained by writing or visiting any District ice of the Workers' Compensation Board. OR B) The DB-120.1 -- Certificate of Disability Benefits Insurance (the business' insurance carrier will send this form to the govemment entity upon request); OR C) DB-155 -- Certificate of Disability Benefits Self-Insurance (the business calls the Board's Self- Insurance Office at S 18-402-0247). Government Officials Local Contacts with the NYS Workers' Compensation Board Govemment Officials should call the Workers' Compensation Board's Enforcement Unit in the nearest district office to notify them of anon-compliant business: Albany Binghamton Brooklyn Buffalo Hauppauge Hempstead (518) 486-3349 (607)721-8334 (718) 802-6870 (716) 842-2056 (631) 952-6698 (516) 560-7742 Manhattan (212) 932-7576 Peekskill (914) 788-5804 Queens (718)523-8409 Rochester (585) 238-8335 Syracuse (315) 423-1141 Please call the Bureau of Compliance at (518) 486-6307 with any general questions regarding WCL Section 220 (8) regarding disability benefits. 27 -27- lure wcs >Fr~unnt 1`imwd~ uetw~n' yY2~1 ( 75a 5157 Fad tyre} w,e+ tmwoe -- ~~ yu pto~onN trrswt# wcos,«rwt ,~,~ rrr~astornm +ae-~e~.~ >rvsw~c:u i 1n•srre sul.oMo• ~oiunwin 111 11Ar/tot+ ~ti~s~ ~ a 17'6 Pleat ylsw.us~n ~ ~1 KoRti ~w ~~, ew.~ s+ ais J~iw xt sraro N FMrft[/ ~ m o.ww.~• O~w Suva 1~ JltA itrd FiDR Ch..rn E~ AF~ICSM7U: Ord stator OUEENS IidGhEi<7Efl 8YRT1CU5E ' Mw91MMWN ~BIEOOIaYN ~RlP/14.0 1419Q Fttt4lrPAleOE 11T66 MW~f1'EAD 1166 PIH~M~ 10tS6A +16 tsltCt ( JG} 677• 14651 (~) 211- bXf t3 ~'$) 8az• Ti901 dd618~12- (1201 (8011}877- Z7 t- t' ~ ~846~ d77- I ~ - IDdd} 7 S 37~~ i 1 ~ 6St Fa>/~ ('318} ' F~ ftt~ j Ftu~- pte) Frod~ 1'565) Fa~ar (J15) 2~e .zs p~ ~p7} Paw (71B} Fsod1(T16} ) F~ ( 78d~371a41 ass-a~•, - - ~r~-p~eo ~xi.e~a ~.ae~~ a~~z1e6 ssz-7v~ Leo-~eo7 .And Certain Out tN•S1>~te Entities, That t~~ew Affictttrvit for NePw Yatk ErKtiies YV~t ivo Em-p~oY'~ York ~tata Worltess' Campensatiat~ Mtilt?r Dissbil"~~~~GpYBra~e is Nflt Re~uirtieci (~ ~.+r•s ~>~ Irk •dota Sotrrd eaaoat sr>ri~t epptksets in ens7-eria3 9uertioe~ shoat this loran. ~tsuat t6d !~ a swen rtitDas'~ ewrp~3r~s alt the gtKtren' Ganes *•~lrfoml c+aaor be rltedM•eva%c1Jru w~or~km` tpn~saJloai - 01' obl~aarivas af~yl~on!`~ •• Tht >lpplicnnt a:ay use this Ati'xiavit ONY,Y_ w show a Ravesnnreclt entity that Near 'livrk State specific v-~orlcers' msuranea is not r+equil+ed. 'ILc sppli~nt may ~ use tiers form tv show either other coaepenslttion and/or disability beaLOfits businesses or those busaiesses' insurance carriers that such inwrairoe is trot rogou+dd. N,pplicsat irtut either fret a mail this comp~kted iaral ta'the e'bmesi NC'1r York St~1te Worloers` Oainperlsatioll turd uflice 11t the fall wipber or address listed do tht top of lids for's- Inooatolehs lEortns gill be ED. sof .and TAN neat to be at reeebved try tlic New York State Workers'. ptei~e sate: K`hiz ststtetaelit ~i.~£..._°t~ ~~nat a(lkbrln sae }enT nf+lber the dAie susmpcd as re~ctEvad by Q6arpe0>wat3br BOill~t. ~i11b af~avit wl qot be ie1Dlp~ted ~ g tfet RFO'rlisn' Camspeal: 8sard. nir a trtrt r y f;O~t RT[Eb RC1R]WI WCI~B-10. the Wo+rke~' Cumptr~ ; $'°i'sar tibe ar}gina~ if sliber a1sR or teat "'~'~' ~ ~"~ P)seafe ~ t lorrll as nod r+etsra to to you ~ fiarrlt m the g~rgmeal elrtity (roar *11ieh poa ere i~egexsti~tg a permit, r~~ ~ ~ ~vernment entity') M ti16 stamped Ucease or eontract. ~ ~ ~P~~n of {Baasit~ Nirias >AS1d Adder} [or n iretaslrelliaenselcaatract Sts~#e of ~ ss.: Csan~ of ? • - f~canr `s aaeme} bed duly aworri, deposes rani says' ~' 1. l~eurJ with the abmre-tto~red business. slap (natr,~ of l s) I am the ~ ~~~ f~ cart vett~o+`r e~c). "i`i'io mlephonC number of tbo basuress is Easiness--a.~. brd~~ ~`~o Fedarol Etnaf'oy'er ldendfic~tion Ntunber +vf the bps (or the So~f 5e~curity . ~ ttf'!"urd that dtm to qty position with tlra abolreraained Numbor of th~o busbtOSS tr~j is b I 11a~e tiro kat>~vvlod~e, irtftyrritatititt dad aut#rerity to malcc this a!f`rdttvnt. mod' my halr-e tdephoac lruti,lyer is 2. My plsa~ensf ~ ~YPe ~ p4~1rrlrl ~lc,anses~coYarroc t 3~7'hst tics sbbve o~srrted bttsi if ~Y~ ~' a ~~i ~h' CMS ~ P~'"id licensdceu~rracrj. ~(~~irwid - Localioo of wlrele +errelt ba parfbrmed In Nc~w'fesk 5tsme it~am tp (firma ~~ ro colupfete 'I1re estTllydo0d diatllar amoasrt asplta3tct is • / work cuo~clared xitkparee~?tcs~rle~corlt-ae1~ 'pp O$T~II`i l+illrW YOtiK 51`J~-'>CBt SP't`•CTI~ IC d. 71aat the abc're named biasbre:s a cxati~yio6 that it is i~PQi"1' RBQiJLRStD IacaM moat ba WdR1CER5' ~~ art die i~ ~ hough 41-~ ~r tics faRo~wipR reason (ta bt al4gibia for ea~mpt+ad, app able to tmi3eitilly d labor, [~ +ta.) tlae trosiircas lit owned by ooe fodi~Wpdf loud is trail • oo~aaabae. Other iblm the owner, iten aro ~ empkryccs, a5' C1•oasowad mrP'ioyoea, Pd't'tl~ e®p1lry~oosr voP°~ v~allurteter: {iacJs~in'8 fmaily tntarbera} or sabcarnractcyrs. leased ~>~~ 29 WClDH-100(9-0'T} {Rcplaata Form t; -I05.Z1 } -29- (~~') STATir OF NEW YOKK WORKERS' COMPENSATION BOARD CERTIFiCA"fE OF INSURANCE COVE E UNDER THE 1VYS ~1TSABILITY BEIt'EFITS LAW PART 1. Ta bt Dora l~ted b Disabili Benefits 'er or Licensed lusurance A ent of that Carrier la. Ltgat Name and Address of Insured (~1se moat Rdc~ess Ib.13 one Number of Iasurcd Insurance Employtr Registration 1d.~1 ~~yet It~Ption Number of insured or Z. Name arad Address of the Entity Requesting Proof of CAvcnsge ($ntlry Being Listed as the t~rtiScete Holder) fns` 1s•': 4. Policy the the Telephone Number Titlt PYtrat N~1 t~l`y 1t~ayo~ounar cam( -itsd ro ~nAte 1VI'S dttabifity 6argJFW f+Rttnxotc+s pollofss sad NYS /fasnsed /-trwranae c~rrtta of thvas lr+ra>rr~ca oanrfers ar,e awdror~sr~ro tastes Fa,-~rl~9-i1~ !. Insurance brokrxs are NtM" authD~ted ~ l~skt t~its~onrt. Under patalty that the named Date Telephon``e~~.N~umber 4 L___-_ M„• ~t~.pR#itl. lYUea Mtb`!a ~~ei,tyfeoeEtlAcMm Qrao~ptedo^ ~P tiip W_.S~ PART 3. Ta be comt~letrd >bP l W~ Aoooedin~ to p~6ormarjoo aalatatnad by the irtlf Disability Bena6ta Lsw with reepcet tD ail ofh~ Date Signed ,~_ i that I s NYS Disabi earria rofera>~d ~verurd NY3 insurrr-oa cerrief) oed rtpeo~taUve as tYYS l~ua Ia9.rsare.t~t o[tM~i 220, l9abd. i Ot'tbe Dtl}gtllry neae~rl~ L+1*'~ IC erupt bt nialkd t. s0 Pa<ek AikAe.~,1'ka York ~~T. ah+ It box "4b^ otpnrt 1 tuts bt:etn +c4erl;~ ~'oric n Board Barad. t3~a rl~ve~aankd anptoyer ha3 eempllad wig doe I~`YS atNY9 Won~mY Coanp~a-pgion 6oMr0 Emptayae) -31- J ~!~-! ~S (11~8~ 33 -33- ~~ PRESENTATION OVERVIEW ~~ ~ WORKERS' COMPENSATION LAW -- SECTIONS 57 AND 220 (8) 1. Definition of Workers' Compensation and Disability Benefits • WC covers job related accidents, injuries, illnesses -- Benefits include all related medical expenses plus 2/3 average weekly wage up to $500 per week effective 7/1/07, $550 per week effective 7/1/08, $600 per week effective 7/l/09 and 2/3 of the State's average weekly wage effective 7/1/10 and thereafter. • DB covers non-job related accidents, injuries, illnesses -- Benefits 1/2 average weekly wage up to $170 per week for maximum of 26 weeks; NO medical expenses. 2. How this insurance benefits both employers and employees • Employees -- No fault, "prompt payment" of benefits • Employers -- Sole remedy coverage - "eliminates" lawsuits and personal liability 3. Why municipal or State employees have to check on this insurance coverage • WCL §57 & §220 (8) requirement • Part of public protection responsibilities 4. What happens if an employer is supposed to have this coverage and doesn't • Employer personally liable for full compensation and medical claim payments; penalties; administrative expenses; and possible criminal charges. • Employee initially paid by Uninsured Employer's Fund - requires a lengthy process before compensation or medical bills are paid. 5. How municipal or State employees check on this insurance coverage (Please note: businesses must supply appropriate form(s) once per year) wC & DB • WC/DB-loo, Affidavit For New York Entities With No Employees And Certain Out Of State Entities, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required; (Affidavits must be stamped as received by the NYS Workers' Compensation Board); WC • C-105.2 -- Certificate of Worker's Compensation Insurance (the business' insurance carrier will send this form to the government entity upon the business' request) PLEASE NOTE: The State Insurance Fund provides its own version of this form, the U-26.3; OR WC • SI-12 -- Certificate of Worker's Compensation Self-Insurance, GSI-105.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance (Please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!) DB • DB-120.1 -- Certificate of Disability Benefits (the business' insurance carrier will send this form to the government entity upon request); OR DB • DB-155 -- Certificate of Disability Benefits Self-Insurance. 6. Out-of--state employers need specific NYS workers' compensation coverage if they have any employees working in New York State. An employer has a full, statutory NYS workers' compensation insurance policy when New York is listed in Item 3A on the Information Page of the employer's workers' compensation insurance policy. Disability benefits coverage is required if the business employs individuals in NYS for more than 30 days in a calendar year. 7. General- Contractors/Subcontractors • To obtain a permit, contract or license from a government agency, general contractors Mi~~T carry a workers' compensation insurance policy if they are hiring subcontractors. -35- LAWS 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 BUILDING PERMIT WITHOUT OBTAINING FROM THE PERMIT APPLICANT EITHER: 1. PROOF DULY SUBSCRIBED THAT WORKERS' COMPENSATION INSURANCE AND DISABILITY BENEFITS COVERAGE ISSUED BY AN INSURANCE CARRIER IN A FORM SATISFACTORY TO THE CHAIR OF THE WORKERS' COMPENSATION BOARD AS PROVIDED FOR IN SECTION FIFTY-SEVEN OF THE WORKERS' COMPENSATION LAW IS EFFECTIVE; OR 2. AN AFFIDAVIT THAT SUCH PERMIT APPLICANT HAS NOT ENGAGED AN EMPLOYER OR ANY EMPLOYEES AS THOSE TERMS ARE DEFINED IN SECTION TWO OF THE WORKERS' COMPENSATION LAW TO PERFORM WORK RELATING TO SUCH BUILDING PERMTf. Implementing Section 125 of the General Municipal Law 1. General Contractors -Business Owners and Certain Homeowners For businesses and certain homeowners listed as the general contractors on building permits, proof that they aze in compliance with Section 57 of the Workers' Compensation Law (WCL) is ONE of the following forms that indicate that they are: • insured (C-105.2 or U-26.3), • a Boazd-approved self-insured employer (SI-12), or • aze exempt (WC/DB-100), under the mandatory coverage provisions of the WCL. Any residence that is not a 1, 2, 3 or 4 Family, Owner-occupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. 2.Owner-occupied Residences For homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence, proof of their exemption from the mandatory coverage provisions of the Workers' Compensation Law when applying for a building permit is to file Form BP-1. • Form BP-1 shall be filed if the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is listed as the general contractor on the building permit, and the homeowner: 0 is performing all the work for which the building permit was issued him/herself, 0 is not hiring, paying or compensating in any way, the individual(s) that is(aze) performing all the work for which the building permit was issued or helping the homeowner perform such work, or 0 has a homeowner's insurance policy that is currently in effect and covers the property for which the building permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued. • If the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is hiring or paying individuals a total of 40 hours or MORE in any week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeowner may not file the "Affidavit of Exemption" Form BP-1, but shall either: 0 acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Boazd to the government entity issuing the building permit (Form C-105.2 or Form U-26.3), OR 0 have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-0ccupied residence (including condominiums) listed on the building permit, provide appropriate proof of workers' compensation coverage, or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Boazd to the government entity issuing the building permit. BP-1 (9-07) Reverse www.wcb.state.ny.us LAWS 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 BUILDING PERMIT WITHOUT OBTAINING FROM THE PERMIT APPLICANT EITHER: 1. PROOF DULY SUBSCRIBED THAT WORKERS' COMI'ENSATION INSURANCE AND DISABILITY BENEFITS COVERAGE ISSUED BY AN INSURANCE CARRIER IN A FORM SATISFACTORY TO THE CHAIR OF THE WORKERS' COMPENSATION BOARD AS PROVIDED FOR IN SECTION FIFTY-SEVEN OF THE WORKERS' COMPENSATION LAW IS EFFECTIVE; OR 2. AN AFFIDAVIT THAT SUCH PERMIT APPLICANT HAS NOT ENGAGED AN EMPLOYER OR ANY EMPLOYEES AS THOSE TERMS ARE DEFINED IN SECTION TWO OF THE WORKERS' COMPENSATION LAW TO PERFORM WORK RELATING TO SUCH BUILDING PERMIT. Implementing Section 125 of the General Municipal Law 1. General Contractors -Business Owners and Certain Homeowners For businesses and certain homeowners listed as the general contractors on building permits, proof that they aze in compliance with Section 57 of the Workers' Compensation Law (WCL) is ONE of the following forms that indicate that they are: • insured (C-105.2 or U-26.3), • a Boazd-approved self-insured employer (SI-12), or • aze exempt (WC/DB-100), under the mandatory coverage provisions of the WCL. Any residence that is not a 1, 2, 3 or 4 Family, Owner-0ccupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. 2.Owner-occupied Residences For homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence, proof of their exemption from the mandatory coverage provisions of the Workers' Compensation Law when applying for a building permit is to file Form BP-1. • Form BP-1 shall be filed ifthe homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is listed as the general contractor on the building permit, and the homeowner: is performing all the work for which the building permit was issued him/herself, 0 is not hiring, paying or compensating in any way, the individual(s) that is(aze) performing all the work for which the building permit was issued or helping the homeowner perform such work, or 0 has a homeowner's insurance policy that is currently in effect and covers the property for which the building permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued. 1 If the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is hiring or paying individuals a total of 40 hours or MORE in any week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeowner may not file the "Affidavit of Exemption" Form BP-1, but shall either: 0 acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Boazd to the government entity issuing the building permit (Form C-105.2 or Form U-26.3), OR 0 have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit, provide appropriate proof of workers' compensation coverage, or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Boazd to the government entity issuing the building permit. BP-1 (9-07) Reverse www.wcb.state.ny.us ^ 4b.) the business is a LLC, LLP, PLLC, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed employees, part- time employees, unpaid volunteers (including family members) or subcontractors. (Mast aaach separate sheer with a list ojaU the partners/members names and also with the signatures of all the partners/ntembers -Limited Partnerships must ONLYIist Genera! 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, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. ^ 4e.) the applicant is a nonprofit entity (under IRS rules). With the exception of clergy or teachers, the nonprofit has no compensated individuals providing any services including subcontractors. ^ 4f.) the business is a farm with less than $1,200 in payroll the preceding calendar yeaz. ^ 4g.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner has no employees, day labor, leased employees, borrowed employees, part-time employees or subcontractors. ^ 4h.) other than the business owner(s) and individuals obtained from a registered temporary service agency, there are no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. Other than the business owner(s), all individuals providing services to the business are obtained from a registered temporary service agency and that agency has covered these individuals for New York State workers' compensation insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation. ^ 4i.) the out-of--state entity has no NYS employees and/or NYS subcontractors AND ALL work related to the permit, license or contract is done outside of NYS; OR ALL employees are direct employees of a government entity outside of New York (Applicant DAIS 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 NOT REQUIRED TO OBTAIN 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.): ^ Sa.) the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation or is a business with no NYS location. In addition, the business does not require disability benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability Benefits Law.) ^ Sb.) the applicant is a political subdivision that is legally exempt from providing statutory disability benefits coverage. ^ Sc.) the applicant is a nonprofit with NO compensated individuals providing services; or is a religious, charitable or educational nonprofit with no compensated individuals providing services except for executive officers, clergy, sextons, teachers or professionals. ^ Sd.) the business is a fans and all employees are farm laborers. ^ Se.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability Benefits Law.) ^ Sf.) other than the business owner(s) and individuals obtained from the temporary service agency, there aze no other employees. Other than the business owner(s), all individuals providing services to the business aze obtained from a registered temporary service agency and that agency has covered these individuals for New York State disability benefits insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation. 6. By signing my name below, I hereby affirm that the statements made herein are true, that I Gave not made any materially false statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that any false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws. I also hereby affirm that if circumstances change so that workers' compensation insurance and/or disability benefits coverage is required, the above-named business will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers' Compensation Board to the government entity listed in item 3 on the front of this form Sworn to before me this Day of 20 Notary Public 4d.) the business is a two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (each individual must own at least one share of stock). Other than the corporate owners, there aze no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. (Must attach separate sheet with a list of the names ojboth owners, and also with both owners'signatures.) (Applicant's Slgnahrre -fast and last name) NYS Workers' Compensation Board Received Stamp WC/DB-100 (9-07) Reverse ^ 4b.) the business is a LLC, LLP, PLLC, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed employees, part- time employees, unpaid volunteers (including family members) or subcontractors. (Must attach separate sheer with a list of aU the partners/lnembers Haines and also with the signatures of all the partners/menrbers - Limited Partnerships must ONLY list General 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, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. ^ 4d.) the business is a two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (each individual must own at least one share of stock). Other than the corporate owners, there aze no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. (Must attach separate sheet with a list of the names of both owners, and also with both owners'signatures.) ^ 4e.) the applicant is a nonprofit entity (under IRS rules). With the exception of clergy or teachers, the nonprofit has no compensated individuals providing any services including subcontractors. ^ 4f.) the business is a farm with less than $1,200 in payroll the preceding calendar year. ^ 4g.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner has no employees, day labor, leased employees, borrowed employees, pazt-time employees or subcontractors. ^ 4h.) other than the business owner(s) and individuals obtained from a registered temporary service agency, there aze no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. Other than the business owner(s), all individuals providing services to the business aze obtained from a registered temporary service agency and that agency has covered these individuals for New York State workers' compensation insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation. ^ 4i.) the out-of-state entity has no NYS employees and/or NYS subcontractors AND ALL work related to the permit, license or contract is done outside of NYS; OR ALL employees are direct employees of a government entity outside of New York (Applicant MAST 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 NOT REQUIRED TO OBTAIN 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.): ^ Sa.) the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation or is a business with no NYS location. In addition, We business does not require disability benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendaz year in New York State. (Independent contractors are not considered to be employees under the Disability Benefits Law.) ^ Sb.) the applicant is a political subdivision that is legally exempt from providing statutory disability benefits coverage. ^ Sc.) the applicant is a nonprofit with NO compensated individuals providing services; or is a religious, charitable or educational nonprofit with no compensated individuals providing services except for executive officers, clergy, sextons, teachers or professionals. ^ Sd.) the business is a farm and all employees are farm laborers. ^ Se.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner has not employed one or more individuals on at least 30 days in any calendaz year in New York State. (Independent contractors are not considered to be employees under the Disability Benefits Law.) ^ Sf.) other than the business owner(s) and individuals obtained from the temporary service agency, there aze no other employees. Other than the business owner(s), all individuals providing services to the business are obtained from a registered temporary service agency and that agency has covered these individuals for New York State disability benefits insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation. 6. By signing my name below, I hereby afino that the statements made herein are true, that I have not made any materially false statements and I make this affidavit under the penalties of perjury. I further affirm that I understand that any false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws. I also hereby affirm that if circumstances change so that workers' compensation insurance and/or disability benefits coverage is required, the above-named business will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers' Compensation Board to the government entity listed in item 3 on the front of this form Sworn to before me this Day of , 20 Notary Public (Applicant's Signature - first and last name) NYS Workers' Compensation Board Received Stamp WC/DB-100 (9-07) Reverse