Form Sh 125 - Application For A Mold Assessment Contractor License Page 3
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1
2
3To submit this application you need to:
•
Use black ink to complete items 1 though 7. Please print clearly.
•
Mail the original, signed application to the New York State Department of Labor, Division of Safety and
Health, License and Certification Unit, State Office Campus, Building 12, Room 161A, Albany, NY 12240.
•
Keep a copy for your records.
•
You must include with your application:
1)
Your non-refundable application fee of $150, see page 1, item 1.
Make your check or money order payable to the Commissioner of Labor. Do not send cash.
2)
A copy of your Mold Assessor Training Course Certificate of Completion form.
This must be from a New York State Department of Labor approved training provider.
3)
A copy of your DBA for each County in which you do business (if applicable) see page 1, item 2b.
4)
Copies of your proofs of insurance:
I.
Worker’s Compensation coverage,
a. C-105.2:
Certificate of Workers’ Compensation Insurance
b. SI-12:
Certificate of Workers’ Compensation Self-Insurance
c. GSI-105.2: Certificate of Participation in Workers’ Compensation Group Self-
Insurance
d. U-26.3:
State Insurance Fund’s version of the C-105.2
e. CE-200:
Certificate of Attestation of Exemption
II. Disability Insurance coverage,
III. Liability insurance coverage, You must submit proof that you have $50,000 in liability
insurance coverage for claims resulting from your licensed activities and operations. See New
York State Labor Law Article 32, and § 932(3)(d) for more information.
For more information please go to
General information:
Any business that engages in mold assessment on a project, advertises that it is a mold
Who needs a Mold
assessment business, or holds itself out as a mold assessment business.
Assessor License?
Any individual engaged in mold assessment.
Mold assessment is defined as any inspection or assessment of property for the purpose
to discover mold, conditions that facilitate mold, and/or any conditions that indicate they
are likely to encourage mold.
What are the
An applicant for a Mold Assessor License must:
qualifications?
•
be eighteen (18) years of age or older,
•
satisfactorily complete a Mold Assessor Training Course from a Department of
Labor approved training provider,
•
pay the statutorily required application fee of $150, and
•
submit proof of:
Workers’ Compensation coverage, if required
o
Disability insurance coverage, if required
o
Liability insurance coverage of at least $50,000 providing coverage for
o
claims from the licensed activities and operations performed according
to New York State Labor Law Article 32.
How do I obtain an
You may obtain a Mold Assessor License application online at
.
application?
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