Confirmation Of Nys Workers' Compensation & Disability Benefits Insurance

Confirmation Of Nys Workers' Compensation & Disability Benefits Insurance - Wic Program

CONFIRMATION OF NYS

NEW YORK STATE DEPARTMENT OF HEALTH

WORKERS’ COMPENSATION

& DISABILITY BENEFITS

Bureau of Supplemental Food Programs, WIC Program

INSURANCE

Vendor Trade Name: __________________________________________________________________________

In order to be considered for authorization as a WIC vendor, you must

indicate compliance with the following and return this form and proof of

insurance with your WIC Vendor Application:

□

Check here if you have New York State Workers’ Compensation Insurance

Section 57 of the New York State Workers’ Compensation Law requires that before any permit, license or contract

is issued by any municipal, county or state government entity, the applicant must be in compliance with NYS

Workers’ Compensation coverage requirements.

The following forms are acceptable as proof of compliance:

C-105.2

Certificate of Workers’ Compensation Insurance

U-26.3

Certificate of Workers’ Compensation Insurance – State Insurance Fund

SI-12

Certificate of Workers’ Compensation Self-Insurance

GSI-105.2

Certificate of Participation in Workers’ Compensation Group Self-Insurance

CE-200

Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability

Benefits Coverage

□

Check here if you have New York State Disability Benefits Insurance

Section 220 of the New York State Workers’ Compensation Law requires that before any permit, license or contract

is issued by any municipal, county or state government entity, the applicant must be in compliance with NYS

disability benefits coverage requirements.

The following forms are acceptable as proof of compliance:

DB-120.1

Certificate of Disability Benefits

DB-155

Certificate of Disability Benefits Self-Insurance

CE-200

Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability

Benefits Coverage

If you do not have New York State Workers’ Compensation and Disability Benefits Insurance, you must

obtain coverage prior to submitting your application. Your application will be considered incomplete and

will be returned to you if you do not provide the above information or if you do not have New York State

Workers’ Compensation and Disability Benefits Insurance.

For information on insurance coverage requirements, contact the following:

NYS Workers’ Compensation Board Website

NYS Workers’ Compensation Board, Bureau of Compliance

1-866-298-7830

Confirmation Of Nys Workers' Compensation & Disability Benefits Insurance - Wic Program

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