Form Db-802 - Employer'S Application To Have Association, Union Or Trustee Plan Accepted As Employer'S Plan Page 2
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2CERTIFICATION BY ASSOCIATION, UNION OR TRUSTEES
STATE OF NEW YORK
COUNTY OF...........................................................................
..........................................................................................................................being duly sworn, deposes and says:
Name of Authorized Official
That he or she is the.......................................................... of the...............................................................................
Name of Association, Union or Trustees
and is duly authorized to execute this affidavit of certification on behalf of said Association, Union or Trustees.
That EMPLOYER became (will become) a participating Employer in the Plan on.................................................that,
during the term of the Plan as accepted by the Chairman of the Workers' Compensation Board, the EMPLOYER'S
participation will continue to be effective until ten days after a written notice of termination is served on the EMPLOYER and
filed with the Chairman of the Workers' Compensation Board by or on behalf of the Association, Union or Trustees.
That the employees specified on this form by the EMPLOYER will be provided benefits under the accepted Plan of this
Association, Union or Trustees.
...............................................................................
Signature of Authorized Official
Sworn to before me this
........................day of..................................................
...................................................................................
Signature of Notary Public
INSTRUCTIONS
1. Each completed form is to be executed by the EMPLOYER, certified by the Association, Union or Trustees, and sworn to
before a notary public before filing.
2. Mail the form for filing, in duplicate, to:
WORKERS' COMPENSATION BOARD
DISABILITY BENEFITS BUREAU
PLANS ACCEPTANCE UNIT
100 BROADWAY-MENANDS
ALBANY, NY. 12241-0005
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
DB-802 (4-04) Reverse
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