New York State Workers' Compensation Board

• a business formed in the State of New York [50(3-b)]
• a business formed in the State of New York for the sole purpose of administering claims but are not a subsidiary of an insurance carrier licensed to write Workers' Compensation policies [50(3-d)]
• or, an insurance carrier licensed by the New York State Department of Financial Services to write Workers' Compensation policies in New York State, or a subsidiary of one [50(3-d)]

Provide proof of current insurance policies or exemption:

• For Workers' Compensation policies, use Certificate of NYS Workers' Compensation Insurance Coverage (Form C-105.2).
• For Disability Benefits policies, use Certificate of Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law (Form DB-120.1).
• For Exemption, use Certificate of Attestation of Exemption (Form CE-200).

Self-insurer's Represntative's Bond Form (CE-200)

Corporate entities must designate an officer of the corporation as the person responsible for ensuring that the corporate entity complies with all the laws, regulations, policies, procedures, and directives relating to the administration of workers' compensation claims in New York State.