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Employees of the Workers’ Compensation Board cannot assist applicants in answering questions in the

following two sections. Please contact an attorney if you have any questions regarding these sections.

7. Please select the reason that the legal entity is NOT required to obtain New York State

Specific Workers’ Compensation Insurance Coverage:

□

The applicant is NOT applying for a workers' compensation certificate of attestation of exemption and will show

a separate certificate of NYS workers' compensation insurance coverage.

□

B. The business is owned by one individual and is not a corporation. Other than the owner, there are no employees,

day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family

members) or subcontractors.

□

C. The business is a LLC, LLP, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a

corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed

employees, part-time employees, unpaid volunteers (including family members) or subcontractors.

□

D. The business is a one person owned corporation, with that individual owning all of the stock and holding all

offices of the corporation. Other than the corporate owner, there are no employees, day labor, leased employees,

borrowed employees, part-time employees, other stockholders, unpaid volunteers (including family members) or

subcontractors.

□

E. The business is a two person owned corporation, with those individuals owning all of the stock and holding all

offices of the corporation (each individual must hold an office and own at least one share of stock). Other than the

two corporate officers/owners, there are no employees, day labor, leased employees, borrowed employees, part-time

employees, other stockholders, unpaid volunteers (including family members) or subcontractors.

□

F. The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for

clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code) with no

compensated individuals providing services except for clergy providing ministerial services; and persons performing

teaching or nonmanual labor. [Manual labor includes but is not limited to such tasks as filing; carrying materials

such as pamphlets, binders, or books; cleaning such as dusting or vacuuming; playing musical instruments; moving

furniture; shoveling snow; mowing lawns; and construction of any sort.]

□

G. The business is a farm with less than $1,200 in payroll the preceding calendar year.

□

H. The applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence.

The homeowner has no employees, day labor, leased employees, borrowed employees, part-time employees or

subcontractors. The homeowner ONLY has uncompensated friends and family working on his/her residence.

□

I. Other than the business owner(s) and individuals obtained from a temporary service agency, there are no

employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including

family members) or subcontractors. Other than the business owner(s), all individuals providing services to the

business are obtained from a temporary service agency and that agency has covered these individuals for New York

State workers' compensation insurance. In addition, the business is owned by one individual or is a partnership

under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those

individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation,

each individual must be an officer and own at least one share of stock). A Temporary Service Agency is a business

that is classified as a temporary service agency under the business’s North American Industrial Classification

System (NAICS) code.

Temporary Service Agency

Name _________________________________________________ Phone #_______________________________

□

J. The out-of-state entity has no NYS employees and/or NYS subcontractors AND ALL work related to the permit,

license or contract is done outside of NYS; OR ALL employees are direct employees of a government entity outside

of New York. Please provide coverage information.

Carrier______________________________________Policy #__________________________________________

Policy start date _____________________________Policy expiration date ________________________________

CE-200APPLY (2/2009)

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Application Form For Certificate Of Attestation Of Exemption From New York State Workers' Compensation And/or Disability Benefits Insurance Coverage - New York State Workers' Compensation Board Page 3

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