Form Db-850 - Application For Acceptance Of Insurance
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1
2STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
DISABILITY BENEFITS BUREAU
100 BROADWAY-MENANDS
ALBANY, NY 12241-0005
APPLICATION FOR ACCEPTANCE OF INSURANCE FORM
Under Section 360.1(b)(1) NYCRR
To: Chair, Workers' Compensation Board
_____________________________________________________________________________________, an insurance
carrier authorized by the Superintendent of Insurance to write contracts insuring the obligations of employers pursuant
to Section 211 of the Workers' Compensation Law, hereby applies under Section 360.1(b)(1) NYCRR for the
acceptance of the attached insurance form, and requests assignment of an identifying number.
1. The attached form is:
Policy
Rider or Endorsement
Supplement
Other (specify) ________________________________________________________
2. This form was filed with the Superintendent of Insurance on _________________ Insurance Carrier's Form
No._______________
3. The above insurance form, if other than a Policy form, will be used with insurance carrier form(s) identified below.
(List insurance carrier form number and Workers' Compensation Board identifying number, if any.)
___________________________________________________________________________________________
4. The following item or items, as checked, correctly describe the form herewith submitted.
a.
The benefits to be provided are the same in all respects as those required by Section 204 of the Workers'
Compensation Law.
b.
The benefits to be provided are the same in all respects and greater in one or more respects than required
by Section 204 of the Workers' Compensation Law.
c.
Other benefits related to disability benefits are to be provided, such as hospital, medical, surgical, etc.
d.
Other benefits not related to disability benefits are to be provided, such as group life, dependent benefits,
etc.
e.
The form as issued will include variable (fill-in) provisions. When coverage under this form is provided for
an employer the certificate of insurance will, by specific reference, and in the same order as listed in the
insurance form, indicate the variable (fill in) provisions contained in the insurance contract as issued.
5. The insurance carrier will, pursuant to Section 360.1(b)(1) NYCRR, and until acceptance of this insurance form has
been revoked by the Chair or approval thereof rescinded by the Superintendent of Insurance, file promptly the
certificate of insurance as prescribed by the Chair for each insurance contract issued using this form.
Date:________________________________
By:____________________________________________________
Signature of Authorized Representative
Tel. Number:__________________________
Title:___________________________________________________
Notice of Acceptance
DB-850 (3-02)
See Instructions on Reverse Side
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