Fill and Sign the Locations Workers Compensation Board New York State Form

STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUTDISCRIMINATION. STATEMENT FOR A GOVERNMENT ENTITY THAT A BUSINESS DOES NOT REQUIRE WORKERS' COMPENSATION AND/OR DISABILITY BENEFITS COVERAGE Applicant's NameBusiness or Trade Name, If Different Applicant's Home Address Business Address (Physical Location), If Different Under penalty of perjury, I certify that the above business does not require Workers Compensation Disability Benefits Coverage because: the business is owned by one individual with no employees and is not a corporation. the business is a partnership under the laws of New York State, and there are no employees.the business is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation, and there are no employees. the business does not require disability benefits coverage at this time since it has not employed one or more individuals on each of at least 30 days in any calendar year. (Please specify other reason) I also agree to acquire appropriate worker's compensation and disability benefits coverage for the above business, if circumstances change so that such coverage is required. Date Signed: By: (Signature of Business Owner, Partner or Corporate Officer) to Title: Requested Effective Dates: from (One Year Maximum) (Business Owners: Please Send Completed Application to nearest WEB Enforcement Unit.) NOTICE ANY FALSE STATEMENT, REPRESENTATION, OR CONCEALMENT WILL SUBJECT YOU TO FELONY CRIMINAL PROSECUTION, INCLUDING JAIL AND CIVIL LIABILITY IN ACCORDANCE WITH THE WORKERS' COMPENSATION LAW In conformance with Sections 57 and 220 Subd. 8 of the Workers' Compensation Law, based on the foregoing certification made by the above business, the Workers' Compensation Board has no objections, at this time, to the issuance of requested permits or contracts. Date Signed: By: (Signature of WCB Employee) Telephone Number: Title: to Please Note: This Statement is valid only from (one year maximum). At the expiration of this term, if the business continues to be named on a permit or contract issued by a government entity, the business must provide that government entity with a new Statement. The business must provide a Certificate of Workers' Compensation and Disability Benefits Coverage to the government entity if circumstances change so that such coverage is required during this period. Further, it is understood that the Board reserves the right to request revocation of the permit or contract if, after investigation, it is found that the above business is required to have workers' compensation and/or disability benefits coverage. "This form cannot be used to waive the workers' compensation rights or obligations of a subcontractor" C-105.21 (3-97) 100 Broadway State Office Building State Office Building 175 Fulton Avenue Menands 41 North Division St. HEMPSTEAD 11550 PEEKSKILL 10566(516) 560-7700 (607) 721-8356 (914) 788-5775 (718) 802-6600 (516) 952-7964 935 James StreetSYRACUSE 13203(315 ) 423-2934 130 Main Street W.ROCHESTER 14614(716) 238-8300 455 Wheeler Rd.HAUPPAUGE 11788 (716) 847-3158 125 Main StreetBUFFALO 14203 180 Livingston StreetBROOKLYN 11248 44 Hawley StreetBINGHAMTON 13901 (58) 474-6674ALBANY 12241 Home Telephone Number Business Telephone Number, If Different Type of Business Federal Employer Identification Number WORKERS' COMPENSATION LAW Section 57 Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Section 220 Subd. 8 Penalties. 8.(a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of suchstate or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees inemployment as defined in this article, and not withstanding any general or special statute requiring or authorizing any such contract, shall not enter into such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. C-105.21 (3-97) Reverse