Form Oc-403.3 - License Application

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State of New York
WORKERS' COMPENSATION BOARD
STOCKHOLDER OF CORPORATION APPLYING FOR LICENSE TO REPRESENT SELF-INSURERS
UNDER SECTION 50 3-b or 50 3-d OF THE WORKERS' COMPENSATION LAW
If applicant corporation is a subsidiary, this form should be completed by chief executive officer of parent corporation.
If additional information is needed, call the Licensing Unit at (1-800) 664-2379.
1. Name of applicant corporation__________________________________________________________
2. Name of stockholder_________________________________________________________________
Address___________________________________________________________________________
3. Stockholder's Social Security No._________________ Federal Employer ID No. __________________
See Privacy Notification below. If you have neither number, explain: __________________________
__________________________________________________________________________________
__________________________________________________________________________________
4. Specify percentage of stock owned______________________________________________________
5. Have you (or if a corporation, the corporation or any of the officers thereof) ever been convicted of a
crime? q Yes
q No
If Yes, state when and give details: _________________________________
__________________________________________________________________________________
Are there any criminal charges now pending against you (or if a corporation, against the corporation or
any of the officers thereof)? q Yes
q No If Yes, give details: _____________________________
__________________________________________________________________________________
__________________________________________________________________________________
6. Do you own stock in any corporation which to your knowledge has been granted self-insurer's status
under the New York State Workers' Compensation Law? q Yes
q No If Yes, give details: ________
__________________________________________________________________________________
__________________________________________________________________________________
7. Do you own stock in any corporation (other than applicant corporation) licensed or authorized to
write workers' compensation insurance in New York State? q Yes
q No
If Yes, give details: _____
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________
Signature of Stockholder of Corporation
(or Chief Executive Officer of Parent Corporation*)
* If application is signed by other than chief executive officer of parent corporation, attach a copy of
corporate resolution delegating the authority to sign on behalf of the signing officer.
PRIVACY NOTIFICATION
The authority to request personal information from you, including identifying numbers such as Federal Social Security and
Federal Employer Identification Numbers, and the authority to maintain such information, is found in Section 5 of the Tax Law.
Disclosure of this information by you is mandatory. The principal purpose for which this information is collected is to enable the
Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns
or may have understated their tax liabilities and to generally identify persons affected by the taxes administered by the
Commissioner of Taxation and Finance. The information will be used for tax administration purposes and for any other purpose
authorized by the Tax Law or the Workers' Compensation Law.
The information collected will be held by the Office of the Secretary, Workers' Compensation Board. All inquiries regarding such
records should be addressed to the Privacy Compliance Officer, Office of the General Counsel, Workers' Compensation Board,
328 State Street, Schenectady, NY 12305. Phone: (518) 486-9564.
OC-403.3 (2-12)

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