Form Db-850 - Application For Acceptance Of Insurance Page 2
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2NOTICE OF ACCEPTANCE OF INSURANCE FORMS
Insurance
Carrier_________________________________________________________________________________________
W.C.B. Identifying No.___________________________ Insurance Carrier Form No.___________________________
Until further notice the attached insurance form is assigned the above W.C.B. Identifying Number.
Acceptance of insurance forms is subject to the requirement that adequate facilities for promptly and efficiently servicing
insured claims shall be provided and maintained by the carrier in locations convenient to every part of the State where
there are places of employment of employers who provide benefits for employees by an insurance contract of the carrier.
The insurance form identified above is accepted for use within the limitations described in the application submitted by
the insurance carrier and subject to the provisions of Article 9 of the Workers' Compensation Law and Regulations
thereunder.
_______________________________
Date of Acceptance
By_______________________________________
Authorized Signature
THIS ACCEPTANCE IS VALID ONLY WHEN COUNTERSIGNED AND BOARD SEAL IS AFFIXED.
I N S T R U C T I O N S
1. This application may be signed only by a representative authorized to act for the Insurance Carrier in matters
relating to the acceptance of insurance forms under the Disability Benefits Law.
2. For each insurance form submitted to the Chair for acceptance:
a. Prepare a separate application in duplicate, and attach firmly to each copy of the insurance form.
b. Enclose four (4) extra copies of the insurance form with the application.
3. Mail completed application and copies of the insurance form to:
WORKERS' COMPENSATION BOARD
DISABILITY BENEFITS BUREAU
100 BROADWAY-MENANDS
ALBANY, NY. 12241-0005
When accepted, duplicate application with appropriate notation of acceptance by the Chair above, will be returned to
the insurance carrier.
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
DB-850 (3-02) Reverse
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