Nys Fair Insurance Information & Samples Page 5
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9TROY W. WAFFNER
ANDREW M. CUOMO
RICHARD A. BALL
Acting Director, New York State Fair
Governor
Commissioner
EXAMPLE OF THE CE-200 EXEMPTION FORM (OBTAINED FROM THE WORKERS’ COMPENSATION BOARD)
Complete
information
about your
business –
must match
what is
printed on
Enter the NYS
your
agreement.
Department
FEIN# must
of Agriculture
match with
and Markets
our records.
as the Agency
CE-200 can be
used for
exemption for
Worker’s
Compensation,
Workers’
Disability, or
both. This
example shows
exemption for
both coverages
Must be
signed by
Valid for
Vendor to
one year
be valid
after date
issued
5
(Rev. 01/17)
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