New York State Department of Labor
Division of Labor Standards
Permit and Certificate Unit
Building 12, Room 266A
State Office Campus
Albany, NY 12240
Verification of Workers’ Compensation/Disability Insurance Coverage
This form is to be completed by Payroll Services for applicants that apply for Certificates of Eligibility to Employ Child Performers.
Submit this form with the application and forms C-105.2 and DB-120.1 from the insurance carriers.
The employees of (enter name and address of applicant)
________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
are covered under the
Workers’ Compensation Policy
Disability Insurance Policy of
(enter name and address of the Payroll Service whose policies cover the employees of the applicant listed above)
_________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I, the undersigned, affirm that I am authorized to submit this verification on behalf of the applicant and Payroll
Service shown above and that a written contractual agreement exists between the applicant and Payroll Service to
provide Workers’ Compensation and Disability Insurance to employed performers.
I certify under penalty of perjury that the information in this verification and all attachments is complete and
accurate to the best of my knowledge.
___________________________________________________________
______________________________________
Authorized Representative Signature
Date
___________________________________________________________
______________________________________
Authorized Representative Name (Please Print)
Title
LS 551 (10-13)
(Attachment of LS 550)
LS 550 (11-13)
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