Application Form For Certificate Of Attestation Of Exemption

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New York State Workers' Compensation Board
Application for Certificate of Attestation of Exemption
from
New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage.
For NYS workers’ compensation exemption, this application may only be completed by entities with no employees or
out-of-state entities obtaining contracts for which ALL work is performed outside of NYS. For NYS disability benefits
exemption, it may only be completed by entities without employees or those with employees, as defined by the NYS
Disability Benefits Law, working in NYS for less than thirty days in a calendar year.
A certificate of attestation of exemption can ONLY be used to attest to a government entity that the applicant requesting a
permit, license or contract from that government entity is not required to carry workers’ compensation and/or disability
benefits insurance.
The application must be completed in its entirety and submitted to the Workers’ Compensation Board by fax or mail. The
application will be processed in the order received and a certificate of attestation of exemption will be mailed to the
applicant. This process may take up to four
weeks.
To obtain a certificate immediately, please use the on-line application at Once the application is
completed on-line, you can immediately print the certificate on your printer.
Please review the separate instructions (form CE-200 instructions) prior to completing this application. Please print
clearly.
1. Applicant Personal Information:
First Name:
____________________________ Last Name: ______________________________________
Street Address: ____________________________________________________________________________
City: ___________________________________ State: ____________________ Zip: _________________
Country (If other than U.S.) __________________________________________________________________
Personal Phone Number ( ______ ) ___________________________
2. Your Title (check only one)
 Sole Proprietor
 Treasurer
 President
 Partner
 Vice President
 Member
 Secretary
 Trustee
 Homeowner
 Board Member
 Other (please provide title) __________________________________________________________
3. Legal Entity Information:
Business Federal ID (If none, enter social security number): _________________________________________
Legal Entity Name: _________________________________________________________________________
Doing Business As Name_____________________________________________________________________
Business Phone: ( _______ )__________________E-mail __________________________________________
 Check here if business address is the same as the applicant’s personal address. If different, enter business
address below.
Business Street Address: _____________________________________________________________________
City: _________________________________ State: _____________________ Zip:_____________________
Country (If other than U.S.) __________________________________________________________________
CE-200APPLY (2/2009)
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