Form Ls 553 - Application Form For A Certificate Of Eligibility

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New York State Department of Labor
Division of Labor Standards
Permit and Certificate Unit, Room 266A
State Office Campus, Building 12
Albany, NY 12240
Application for a Certificate of Group Eligibility to Employ Child Performers
A.
Submission Instructions
An employer must obtain a Certificate of Group Eligibility to Employ Child Performers before employing any group
of child performers for the purpose of creating a background or crowd scene. Performers covered by this Group
Certificate do not need to provide a copy of a Child Performer Permit. A Certificate of Group Eligibility is valid for a
maximum of two days of employment, which need not be consecutive.
To obtain a Group Certificate:
Complete Parts B, C and D of this application.
Attach proof of New York State Workers’ Compensation and Disability Insurance.
o If you currently have employees in New York, you must provide proof of coverage for those New York State
workers by attaching copies of Form C-105.2 and DB-120.1, obtainable from your insurance carrier; or
o If you are currently exempt from this requirement, complete Form CE-200 attesting that you are not required
to obtain New York State Workers’ Compensation and Disability Insurance Coverage. Information on and
copies of this form are available from any district office of the Workers’ Compensation Board or from their
website at
. Click on “WC/DB Exemptions,” then click on “Request for WC/DB
Exemptions.”
Attach a check for $200.00 made payable to the Commissioner of Labor.
Mail this completed application and all required documents to the address listed above.
If you have any questions, call (518) 457-1942, e-mail
CPinfo@labor.ny.gov
, or visit the Department’s website at
.
B.
Group Employer Information
1. Employer Name _________________________________________________________________________________
2. Employer Certificate Number (if applicable)
3. Type of business organization (check one)
Corporation
Sole Proprietorship
Partnership
Limited Liability Company
Limited Liability Partnership
4. Corporate Officers (if any) (list additional names and titles on back)
Name ____________________________________________
Title __________________________________
5. Employer FEIN ___________________________________
6. BusinessAddress ________________________________________________________ City ____________________
State/Province/Region __________________ Postal Zip Code _________________ Country ___________________
Phone _____________________ Fax ____________________________ E-mail ___________________________
7. Mailing Address (if different) ______________________________________________City ___________________
State/Province/Region __________________ Postal Zip Code _________________ Country ___________________
LS 553 (11-13)
1

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