Form Ls 550 - Application For A Certificate Of Eligibility To Employ Child Performers/verification Of Workers' Compensation/disability Insurance Coverage Form
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4New 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 Eligibility to Employ Child Performers
A.
Submission Instructions
A Certificate of Eligibility to Employ Child Performers must be obtained prior to employing any child performer. Certificates are renewable every
three (3) years. To obtain or renew a certificate:
•
Complete Parts B, C, D and E of this application.
•
Attach proof of New York State Workers’ Compensation and Disability Insurance.
If you currently have employees in New York, you must provide proof of coverage for those New York State workers by attaching
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copies of Form C-105.2 and DB-120.1, obtainable from your insurance carrier.
If you are currently exempt from this requirement, complete Form CE-200 attesting that you are not required to obtain New York
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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.”
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Attach a check for the correct amount from Section D, made payable to the Commissioner of Labor.
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Sign and mail this completed application and all required documents to the address listed above.
gov
If you have any questions, call (518) 457-1942, e-mail
CPinfo@labor.ny.
or visit the Department’s website at
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B.
Type of Request (check one)
New
Renewal Current Certificate Number _______________________________________________
Are you seeking this certificate to employ child models?
Yes
No
C.
Employer and Employment Information
1.
Employer Name ____________________________________________________________________________________________________
2.
Type of business organization (check one)
Corporation
Sole Proprietorship
Partnership
Limited Liability Company
Limited Liability Partnership
3.
Corporate Officers, if any (list additional names and titles on back)
Name _______________________________________________
Title __________________________________________________
4.
Employer FEIN __________________________________
5.
Business Address _________________________________________________________________ City _______________________________
State/Province/Region __________________ Postal Zip Code _________________ Country _________________ Phone _____________________
Fax _________________________________________ E-mail ____________________________________________________________________
6.
Mailing Address (if different) ________________________________________________________City ______________________________
State/Province/Region __________________ Postal Zip Code _________________ Country _________________ Phone _____________________
7.
Location(s) of Employment of Child Performers ____________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
8.
Type of Employment (e.g. movie, play, commercial, etc.) _____________________________________________________________________
LS 550 (11-13)
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