| DB 120.1 (5/06) |
Certificate Of Insurance Coverage Under The NYS Disability Benefits Law |
Employers insured for NYS statutory disability benefits insurance through an insurance carrier. |
Filed with the government agency issuing a permit, license or contract. The DB-120.1 must be completed by either the NYS statutory disability benefits insurance carrier, or a licensed NYS insurance agent of that carrier. |
Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from either their NYS statutory disability benefits insurance carrier or a licensed NYS insurance agent of that carrier. Carriers and their licensed agents may contact the Board's Bureau of Compliance to obtain this form. |
WC/DB-100 (9/07)
(Replaces Form C-105.21) |
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 |
Applicants for permits, licenses or contracts from State, county or municipal agencies in New York State that are not required to carry NYS workers' compensation and/or disability benefits insurance coverage. |
Workers' Compensation Board (by mail or fax - see form for addresses and fax numbers) |
These affidavit forms can ONLY be used to attest to a government entity that an applicant requesting a permit, license or contract from that government entity is not required to carry NYS workers' compensation and/or disability benefits insurance. (Instructions) |
| C-DB-22 |
Employer's Statement (for Form DB-450) (NY State Insurance Fund) |
This is a New York State Insurance Fund  form.
The State Insurance Fund has pre-printed Form DB-450 with the Employer's Statement on the reverse. |
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| DB-102 (10/07) |
Information for Employer Regarding Disability Benefits Law |
General DBL information made available to the public. |
Not filed |
Not filed |
| DB-118 (10/07) |
Employer's Statement for the Purpose of Terminating Status as a Covered Employer |
Employer |
In TRIPLICATE to:
NYS Workers' Compensation Board
Disability Benefits Bureau
100 Broadway
Albany, NY 12241 |
After the end of any calendar year in which the employer did not employ one or more employees on each of thirty days |
| DB-120 (10/07) |
Notice of Compliance - Disability Benefits Law |
Employers insured for disability benefits through an insurance carrier or Board-approved self-insurance. |
This form is not filed. It must be completed with identifying insurance information and displayed in the workplace. |
Upon securing of disability benefits insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent. Board-approved self-insurers may contact the Board's Forms Department. |
| DB-125 (2/05) |
Employer Identification Card |
Employer |
Given to employees to provide information to facilitate filing of DB claims. |
Issued to employees upon separation from employment. |
| DB-135 (8/03) |
Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (No Employee Contribution) |
Employer |
WCB, Disability Benefits Bureau, Albany |
To voluntarily cover employees for whom DB is not required under the Law with no employee contributions to the cost of the coverage. |
| DB-136 (8/03) |
Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (Employee Contribution) |
Employer |
WCB, Disability Benefits Bureau, Albany |
To voluntarily cover employees for whom DB is not required under the Law with employee contributions to the cost of the coverage. |
| DB-212.3 (1/04) |
Notice of Election of a Corporation Which is Required to Have Disability Benefits Coverage for its Employees to Exclude the Sole Shareholder Officer or One of the Two or Both Shareholder Officers of the Corporation from Such Coverage |
Sole Shareholder Officer(s) of a Corporation |
File with insurance carrier. Board-approved self-insured employers file with WCB Self-Insurance Office. Board-approved group self-insured's file with the WCB Self-Insurance Office and also with your group administrator. |
Officers are deemed included in insurance contract until election to exclude is filed. |
| DB-212.5 (11/06) |
Notice of Election to Voluntarily Exclude Spouse from Coverage |
Employer |
File with carrier or, if Board-approved self-insurer (or no carrier and spouse is only employee), with the WCB. |
Upon decision to voluntarily exclude spouse from DB coverage. |
| DB-310.3 (10/07) |
Form Letter Requesting Medical Information |
Claimant/Employer |
File with the Special Fund for DB or the employer's DB carrier |
Whenever additional medical proof of disability is needed. |
| DB-791 (2/00) |
Tables of Permanent Contributions |
Reference table of employee contributions for employer use |
Not filed |
Not filed |
| DB-802 (4/04) |
Employer's Application to Have Association, Union or Trustee Plan Accepted as Employer's Plan |
Employer files form after Association, Union or Trustee has signed it. |
Disability Benefits Bureau, Plans Acceptance Unit |
When an employer becomes a participant in a plan administered by an association, union or trust. |
| DB-820/829 (5/07) |
Certificate/Cancellation of Insurance |
Carriers insuring employers for disability benefits through Plan Coverage, Enriched Coverage, or Class Coverage. |
ONLY insurers providing Plan Coverage, Enriched Coverage, or Class Coverage file this paper form with the Disability Benefits Office at the Workers' Compensation Board to show proof of statutory disability benefits coverage. |
Upon writing a disability benefits policy for Plan Coverage, Enriched Coverage, or Class Coverage. |
