Affidavit For New York Entities With No Employees And Certain Out Of
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2NYS WCB
NYS WCB
NYS WCB
NYS WCB
NYS WCB
WC/DB100/101
NYS WCB
State Office
WC/DB100/101
NYS WCB
WC/DB100/101
NYS WCB
WC/DB100/101
NYS WCB
WC/DB100/101
111 Livingston
220 Rabro
215 W. 125th
168-46 91st
WC/DB100/101
Building
WC/DB100/101
WC/DB100/101
WC/DB100/101
NYS WCB
NYS WCB
100 Broadway
St.
107 Delaware
Drive
175 Fulton
St.
41 North
Ave.
44 Hawley
WC/DB100/101
WC/DB100/101
Menands
22nd Floor
Ave.
Suite 100
Ave.
3rd Floor
Division St.
3rd Floor
130 Main St.
935 James St.
Street
ALBANY
BROOKLYN
BUFFALO
HAUPPAUGE
HEMPSTEAD
NEW YORK
PEEKSKILL
QUEENS
ROCHESTER
SYRACUSE
BINGHAMTON
12241
13901
11201
14202
11788
11550
10027
10566
11432
14614
13203
(866) 750-
(866) 802-
(800) 877-
(866) 211-
(866) 681-
(866) 805-
(800) 877-
(866) 746-
(800) 877-
(866) 211-
(866) 802-
5157
3604
1373
0645
5354
3630
1373
0552
1373
0644
3730
Fax# (518)
Fax# (607)
Fax# (718)
Fax# (716)
Fax# (631)
Fax# (516)
Fax# (212)
Fax# (914)
Fax# (718)
Fax# (585)
Fax# (315)
473-9166
721-8464
802-6642
842-2155
952-7966
560-7807
316-9183
788-5793
291-7248
238-8341
423-2938
Affidavit For New York Entities With No Employees And Certain Out Of State Entities, That New
York State Workers’ Compensation And/Or Disability Benefits Insurance Coverage Is Not Required
(Please contact an attorney if you have any questions regarding this form.)
Because this is a sworn affidavit, employees of the Workers’ Compensation Board cannot assist applicants in answering questions about this form.
**This form cannot be used to waive the workers’ compensation rights or obligations of any party.**
The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers’
compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other
businesses or those businesses’ insurance carriers that such insurance is not required.
Applicant must either fax or mail this completed form to the closest New York State Workers’ Compensation Board office at the
fax number or address listed on the top of this form
.
Incomplete forms will be returned, UNSTAMPED.
Please note: This statement must FIRST be notarized and THEN sent to be stamped as received by the New York State Workers'
Compensation Board. This affidavit will not be accepted by government officials one year after the date stamped as received by
the Workers’ Compensation Board.
UPON RECEIPT
OF A FULLY COMPLETED FORM WC/DB-100, the Workers’ Compensation Board will stamp this
form as received and return it to you by either mail or fax within 5 business days. Please provide a copy (or the original, if
required by the government entity) of this stamped form to the government entity from which you are requesting a permit,
license or contract.
____________________________________________________________
In the Application of (Business Name and Address)
___________________________________________
___________________________________________
___________________________________________
for a __________________________ permit/license/contract
State of ___________________ )
) ss.:
County of _________________ )
►
1.___________________________________ (applicant’s name) being duly sworn, deposes and says:
1a) I am the __________________ (position) with the above-named business, a/an _______________________(nature of
business—e.g,. building contractor, occupational therapist, food cart vendor, etc). The telephone number of the business is
(_____)___________________. The Federal Employer Identification Number of the business (or the Social Security
Number of the business owner) is _________________________. I affirm that due to my position with the above-named
business I have the knowledge, information and authority to make this affidavit.
2. My personal address is __________________________________________________ and my home telephone number is
(_____)___________________.
3. That the above named business is applying for a ____________________________________ (type of permit/ license/contract
applying for) from ___________________________________________ (governmental entity issuing the permit/ license/contract).
3a){Optional -- Location of where work will be performed in New York State_____________________________________________
_________________________________________________ from ______________to______________ (dates necessary to complete
work associated with permit/license/contract). The estimated dollar amount of project is ___________________________________. }
4. That the above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC
WORKERS’ COMPENSATION INSURANCE COVERAGE for the following reason (to be eligible for exemption, applicant must be
able to truthfully check ONE of the boxes from 4a. through 4i.):
4a.) the business is owned by one individual and is not a corporation. Other than the owner, there are no employees, day labor,
leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors.
WC/DB-100 (9-07) {Replaces Form C-105.21}
(Over)
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