1987/2007 (16)- ~~ PRESENTATION OVERVIEW ~~
WORKERS' COMPENSATION LAW -- SECTIONS 57 AND 220 SUBD. 8
1. Definition of Workers' Compensation and Disability Benefits
• WC covers job related accidents, injuries, illnesses -Benefits 2/3 average weekly wage up to $400 per week
plus all related medical expenses.
• 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
• §57 & §220 WCL 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 - a process that takes two to three years before
compensation or medical bills are paid.
S . 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-100, Affidavit For New York Entities And Any Out Of State Entities With No Employees,
That New York State Workers' Compensation AndlQr Disability Benefits Insurance Coverage Is
Not Required; OR WC/DB-101,
(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 • Either the DB-120.1 - Certificate of Disability Benefits Insurance OR the DB-820/829
Certificate/Cancellation ofInsurance (the business' insurance carrier will send one of these fornis 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 meet any of the following criteria:
• Permanent NYS Location
• Hire an employee (or subcontractors) in NYS
• Pay over $50,000 per year to employees while they work in NYS
• Employees (or subcontractors) assigned to work over 90 days in NYS during a calendar year.
Disability benefits coverage is required if the business employs individuals in NYS for more than 30 days in a calendar year.
7. General Contractors/Independent Contractors/Subcontractors
• General Contractors must get a workers' compensation insurance policy if they hire any subcontractors or
independent contractors. •
November 3, 2003
WORKERS' COMPENSATION REQUlh. ~~,; BINDER WCL 57
To comply with coverage provisions of the Workers' Compensation Law, businesses must:
A) be legally exempt from obtaining workers' compensation insurance coverage; or
B) obtain such coverage from insurance carriers; or
C) be self-insured or participate in an authorized group self-insurance plan.
To assist State and municipal entities in enforcing Section 57 of the Workers' Compensation Law, businesses
requesting pennits or seeking to enter into contracts MUST provide ONE of the following forms to the
government entity issuing the permit or entering into a contract:
A) WC/DB-100, Affidavit For New York Entities And Any Out Of State Entities With No
Employees, That New York State Workers' Compensation And/Or Disability Benefits
Insurance Coverage Is Not Required; OR
B) C-105.2 -- Certificate of Workers' Compensation Insurance (the business' insurance carrier will
send this form to the government entity upon request) PLEASE NOTE: The State Insurance Fund
provides its own version of this form, the U-26.3; OR
C) SI-12 -- Certificate of Workers' Compensation Self-Insurance (the business calls the Board's Self-
Insurance Office at 518-402-0247), OR GSI-105.2 -- Certificate of Participation in Worker's
Compensation Group Self-Insurance (the business' Group Self-Insurance Administrator will send
this form to the government entity upon request).
DISABILITY BENEFITS REQUIREMENTS UNDER WCL §220 SUBD 8
To comply with coverage provisions of the Disability Benefits Law, businesses may:
A) be legally exempt from obtaining disability benefits insurance coverage; or
B) obtain such coverage from insurance carriers; or
C) be self-insured.
Accordingly, to assist State and municipal entities in enforcing Section 220 Subd. 8 of the Disability Benefits
Law, businesses requesting permits or seeking to enter into contracts MUST provide ONE of the following
forms to the entity issuing the permit or entering into a contract:
A) WC/DB-100, Affidavit For New York Entities And Any Out Of State Entities With No
Employees, That New York State Workers' Compensation And/Or Disability Benefits
Insurance Coverage Is Not Required; OR
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 (the business calls the Board's Self-
Insurance Office at 518-402-0247).
(Affidavits must be stamped as received by the NYS Workers' Compensation Board)
(Affidavits must be stamped as received by the NYS Workers' Compensation Board)
First Cardinal
C O R P O R A T I O N
7/14/2003
Town of Wappinger
PO Box 324
Middlebush Road
Wappingers Falls, NY 12590
RE: WORKERS' COMPENSATION CARRIER CERTIFICATE # 007000000303103
Sloper-Willen Community Ambulance Servic
To whom it may concern:
Our records reflect that you are a certificate holder on the
above captioned certificate.
Please be advised that this employer is under
cancellation notice to be effective on 8/14/2003.
Should the policy be reinstated, your office will be
notified.
If you have any questions regarding this matter, please
contact our office.
T n you,
~ . ~r~ ~ ~ ~~ ~~~~; ~~~
~~ ~
POLIO SERVICES DEPARTMENT
pc: File
Agent#: 1 First Cardinal Corp.
Admtntstrators of Cardinal COMP~~"
N!'OJiicer: AI RA NY HI; FFAI () I(JN (. IS I,AVD MANfIATI'AN
kO CH ESTER SYRAC U}E MA OJj~rrr: BOSTON SI'kING4I4lD
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RE
TowN CLERK
10 British American Blvd.
Latham, NY 12110
518-213-1900
866-850-COMP (2667)
Fax 518-213-1901
www.firstcardinal.com
NEW YORK STATE INSURANCE FUND
199 CHURCH STREET NEW YORK N.Y. 10007-1100
1-8$8-997-3863
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
LOVELL SAFETY MGMT CO L L C
125 MAIDEN LANE JAN 1 ~ ~3
NEW YORK NY 10038
SUPERVI~R'S OFFICE
TOWN OF WAPPINt~ER
»: ~ R ~iQE3:: E C3'~ R~C~:: $Y::'I'WI ~::lr~€~~IK:~CA'Ff;: ~: ~ :::::::::::::::
:~:~:::~~:01:1:2DL:t~f::;TO::::~4~1 {l~:1~2fl04~:::~::~:::;:::;::::~:
POLICYHOLDER
P J EXTERIORS INC
1589 ROUTE 376
WAPPINGERS FALLS
NY 12590
POLICY NUMBER
G 1003 277-9
DATE
12 09/2002
CERTIFICATE NUMBER
CERTIFICATE HOLDER
TOWN OF WAPPINGERS
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS NY 12590
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE
INSURANCE FUND UNDER POLICY N0. 1003 277-9 UNTIL 4/01/2004 COVERING THE ENTIRE
OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK-
ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK,
EXCEPT AS INDICATED BELOW.
IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 4/01/2004 IN SUCH MANNER AS
TO AFFECT THIS CERTIFICATE, 30 DAYS WRITTEN NOTICE OF SUCH CANCELLATION
WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO
ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE
FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE.
THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION.
U-26.3
THE STATE INSURANCE FUND
DIRECTOR, INSURANCE FUND UNDERWRITING
22$83 CERT02-2/2001
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
APPLICATION FOR CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
The undersigned Employer desires to obtain a Certificate of Workers' Compensation Insurance from the
Insurance Carrier Empire State Transportation Trust
as satisfactory proof required under the provisions of Section 57 of the W orkers' Compensation law, to be filed with
Sloper Willen Community Ambulance
Name
(Nome o/Bweau, Departmera Corporation, Frm or bWmduary
Address.
P.O. Box 575, 16 Middlebush Road, Wappingers Falls, NY 12590
Locations of (operations.
Town of Wappinger
Date operations to begin: ON GOING ~
Telephone No. ~~~^ Z~t'~ 3 77 ~ Signature
NOTE This application must be sgned by the Employer If an indlvlduai, or If a I copartnerhlp by a member of the
copartnenhip, or by an officer if a corporation
This is to certify that
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
Sloper Willen Community Ambulance
is insured wdh the Empire State Transportation Trust
under Policy No
00098726
covering the entire obligatwn of this employer for workers' compensation
under the New York W orkers' Compesation Law with respect to the locations named in the foregoing application
O 1 /01 /03 O 1 /01 /04
The policy term, covers the penod from to
If said policy Is changed or canceled dunng its term, In such manner as to affect this Cert~cate, thirty (30) days
written notice of such change or cancellation [ten (to) days wntten notice in the event of cancellation for non-
payment of premium] will be given to
Town of Wappinger, P.O. Box 324, Middlebush Road, Wappingers Falls, NY 12590
(Name of&mau, DepertmeM, Corporation, Form or bMinouaQ (AOd~eas)
m accordance with whose requirements, this Certificate has been issued. Notice by registered or certified mail,
return receipt requested, so addressed shall be sufficient commpliance with this provision
Carver Empire State Transportation Trust
Telepnone No. 845-855-3300
By
(sgnar re) (a )
Tftle
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WRH DISABIL(T1E3 WmiOLR DISCRIMWATION
'JAN 2 32003
wisoR'S QFFICE
OF WAPPINGER
C-+os 2 (+o~>
The Daniels Agency
January 17, 2003
Louise Dalton
Sloper Willen Community Ambulance
PO BOX 575, 16 Middlebush Road
Wappingers Falls, NY 12590
RE: Certificate of Insurance - Town of Wappinger
Dear Ms. Dalton:
Enclosed please find two copies of a certificate of insurance
issued to the Town of Wappinger. Please sign one and forward
directly to the Town and sign the second one and forward to the
Empire State Transportation Trust at your earliest convenience.
Should you have any questions or need anything further, please
feel free to give me a call.
Sincerely,
~r,~~~ ~~~~~
Angela Nash
Customer Service Representative
AMN/1002056 _'< .. , ,:: _ ...::~,: _:.:~
527 Route 22 • Pawling, NY 12564-1200 • (845) 855-3300
FAX (845) 855-1860 • Email: daniels@danielsagency.com • www.danielsagency.com