Form Db-802 - Employer'S Application To Have Association, Union Or Trustee Plan Accepted As Employer'S Plan

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State of New York

WORKERS' COMPENSATION BOARD

DISABILITY BENEFITS LAW

EMPLOYER'S APPLICATION TO HAVE ASSOCIATION, UNION OR

TRUSTEE PLAN ACCEPTED AS EMPLOYER'S PLAN

An EMPLOYER participating in a Plan and Agreement of an association of employers or employees, union or

trustees shall file this application in duplicate if the Plan is insured or in triplicate if the Plan is self-insured.

____________________________________________________________________

Name of Employer

(HEREIN CALLED THE EMPLOYER)

____________________________________________________________________

Name Under Which Business is Conducted

____________________________________________________________________

Number and Street

City

State

Zip Code

____________________________________________________________________

Federal Employer's Identfication Number (If Sole Proprietor, Give Social Security No.)

____________________________________________________________________

Employer's U.I. Registration No. (If None, Give Reason)

A. The EMPLOYER requests acceptance of this PLAN and AGREEMENT identified by W.C.B. Plan Number_________________________________

of ________________________________________________________________________________________________as the EMPLOYER'S Plan.

Association, Union or Trustees

1. The Plan covers the EMPLOYER'S employees as follows:

All employees eligible for benefits under the New York Disability Benefits Law.

All employees eligible for benefits under the Disability Benefits Law except those classes of employees eligible to receive Benefits under another

policy or plan accepted by the Chair.

Only the following class or classes of employees:___________________________________________________________________________

___________________________________________________________________________________________________________________

2. Number of EMPLOYER'S employees covered under this Plan_____________________________________________________________________

3. The EMPLOYER became (will become) a Participating Employer in the Plan on________________________________________________________

(Date)

B. The EMPLOYER agrees:

1. That all eligible employees will be provided Benefits either by the Plan or in one or more of the ways specified in Sec. 211 of the Disability Benefits Law.

2. That any excess of the aggregate contributions of employees over the cost of providing Benefits and any uncommitted balance of employee

contributions remaining at the termination of this Plan shall be distributed or applied for the sole benefit of employees or otherwise be applied or

disposed of pursuant to Sec. 210, subdivision 4, and Sec. 216 of the Disability Benefits Law.

3. That the Plan Benefits will be continued until the Employer has filed written notice with the Chair of the termination of the Plan.

_________________________________________________________

Employer

Date Signed_______________________________________________

By_________________________________________________________

Signature of Owner, Partner or Authorized Officer

Telephone No.:_____________________________________________

Title________________________________________________________

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