Nys Fair Insurance Information & Samples (Page 6 of 9) in pdf

Nys Fair Insurance Information & Samples Page 6

TROY W. WAFFNER

ANDREW M. CUOMO

RICHARD A. BALL

Acting Director, New York State Fair

Governor

Commissioner

2. DISABILITY INFORMATION:

Workers’ Compensation Law (WCL) §57 & §220 requires the heads of all municipal and state entities to ensure that

businesses applying for permits, licenses or contracts document that they have appropriate workers’ compensation

(page 2-3) and disability benefits insurance coverage (page 6-7); or document that they are exempt from such coverage

(page 4-5). These requirements apply to both original contracts and renewals, whether the governmental agency is

having the work done or is simply issuing the permit, license or contract. Failure to provide proof of such coverage or a

legal exemption may result in the termination of the Agreement.

To comply with the coverage requirements ONE of the following forms for Workers Compensation must be provided to the

Department:

A. CERTIFICATE OF DISABILITY BENEFITS INSURANCE:

Acceptable forms for proof of Disability must be submitted on one of the following (OR a CE-200 Waiver see page

4-5):



Form DB-120.1



Form DB-155

Please direct all questions to one of the following; New York State Workers’ Compensation Board at 518-486-6307, their

toll free number at 877-632-4996 or go to the New York State Workers’ Compensation Board’s Website:

or contact James Doolittle at 315-423-1141.

See the following page for an example of a Certificate of Disability Coverage.

(Rev. 01/17)

Nys Fair Insurance Information & Samples Page 6