NYC BOARD HEALTH

NYC Department of Health and Mental Hygiene now requires that all food service providers have workers compensation and disability insurance or be certified that they do not require it.

Advantage Brokerage will get you certified as an exempt entity

We will get you the workers compensation and disabiity poicies you need for the NYC Department of Mental Health Licensing.

Call Thomas McGovern (929) 290-8609 for details

Forms that are required by the NYC Department of Healthand Mental Hygiene are

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.
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.

If the form you are looking for is not listed above, or in the list of Common Board Forms, please e-mail the Board's Forms Department.

Thomas McGovern, MBA, CVA

Sanjay Agrawal, President

Kedar Gupta, Director

Augustine Sampa, Director

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We service the following areas: Queens, Brooklyn, Manahattan, Bronx, Staten Island, Kings County, Richmond County, Nassua County, Suffolk county,Astoria, Ditmars, Steinway, Bayside, Bay Terrace, Oakland Gardens, Belle Harbor, Bellerose. Breezy Point. Broad Channel. Cambria Heights. College Point. Corona. Douglaston, Douglas Manor, East Elmhurst, Elmhurst, Far Rockaway, Arverne, Bayswater, Edgemere, Flushing, Auburndale, Kew Gardens Hills, Floral Park, Forest Hills, Forest Hills Gardens, Fresh Meadows, Glendale, Glen Oaks, Hollis, Hollis Hills, Holliswood, Howard Beach, Lindenwood, Jackson Heights, Jamaica, Briarwood, Jamaica Estates, Jamaica Hills, South Jamaica, Kew Gardens, Laurelton, Little Neck, Long Island City, Hunters Point, Ravenswood, Queensbridge, Maspeth, Middle Village, New Hyde Park, Ozone Park, Queens Village, Rego Park, LeFrak City, Richmond Hill, Ridgewood, Rockaway Beach, Rosedale, Saint Albans, Springfield Gardens, South Ozone Park, Sunnyside, Whitestone, Beechhurst, Malba, Woodhaven, Woodside--- All of New York State

Queens Neighborhood with zip codes

Arverne , 11692, Astoria Heights , 11370 , Astoria , 11102, 11103 , 11105 , Auburndale , 11358, Bay Terrace , 11360 Bayside , 11359, 11360, 11361 Bayswater , 11691 Beechhurst , 11357 Bellaire , 11427, 11428, 11429
Belle Harbor , 11694 Bellerose , 11426 Blissville , 11101 Breezy Point , 11697 Briarwood , 11435 Broad Channel , 11693 Cambria Heights , 11411 College Point , 11356 Corona , 11368 Ditmars , 11005, 11370 Douglaston , 11362, 11363 , Dutch Kills , 11101 , East Elmhurst , 11369, 11370, 11371 , Edgemere , 11690 , Elmhurst , 11373 , Far Rockaway , 11096, 11690, 11691, 11692, 11693, 11694, 11695, 11697 , Floral Park , 11001, 11002, 11003, 11004, 11005 , Flushing , 11351, 11352, 11354, 11355, 11356, 11357, 11358, 11359, 11360, 11361, 11362, 11363, 11364, 11365, 11366, 11367, 11368, 11369, 11370, 11371, 11372, 11373, 11374, 11375, 11377, 11378, 11379, 11380, 11381, 11385, 11386, 11390 , Forest Hills Gardens , 11375 , Forest Hills , 11375
Fresh Meadows , 11365, 11366 , Fresh Pond , 11385 , Glen Oaks , 11004 , Glendale , 11385 , Hammels , 11693
Hillcrest , 11365, 11366 , Hollis Hills , 11427 , Hollis , 11423 , Holliswood , 11423 , Howard Beach , 11414
Hunters Point , 11101 , Jackson Heights , 11372, 11370 , Jamaica , 11405, 11411, 11412, 11413, 11414, 11415, 11416, 11417, 11418, 11419, 11420, 11421, 11422, 11423, 11424, 11425, 11426, 11427, 11428, 11429, 11430, 11431, 11432, 11433, 11434, 11435, 11436, 11439, 11451, 11499 , Jamaica Estates , 11423, 11432
Jamaica Hills , 11432 , Kew Gardens Hills , 11367 , Kew Gardens , 11415, 11418, 11424 , Laurelton , 11413
LeFrak City , 11368 , Linden Hill , 11354 , Lindenwood , 11414 , Long Island City , 11101, 11102, 11103, 11104, 11105, 11106, 11109 , Little Neck , 11362, 11363 , Malba , 11357 , Maspeth , 11378 , Meadowmere , 11422
Middle Village , 11379 , Murray Hill , 11358 , Neponsit , 11694 , New Hyde Park , 11040, 11042 , North Shore Towers , 11005 , Oakland Gardens , 11364 , Ozone Park , 11416, 11417 , Pomonok , 11365 , Queens Village , 11427, 11428, 11429 , Queensboro Hill , 11355 , Queensbridge , 11101 , Ravenswood , 11106 , Rego Park , 11374 , Richmond Hill , 11418 , Ridgewood , 11385, 11386 , Rochdale Village , 11434 , Rockaway Beach , 11693
Rockaway Park , 11694 , Rosedale , 11422 , Roxbury , 11697 , Saint Albans , 11412 , South Jamaica , 11435, 11433, 11436, 11434 , South Ozone Park , 11420, 11436 , Springfield Gardens , 11413 , Sunnyside Gardens , 11104 , Sunnyside , 11104 , Tudor Village , 11417 , Whitestone , 11357 , Willets Point , 11368 , Woodhaven , 11421 , Woodside , 11377 ,

Brooklyn Neighborhood with zip codes

Albemarle-Kenmore Terrace, 11226, Bath Beach 11214, Bay Ridge, 11209, Bedford Stuyvesant, 11216, Bensonhurst, 11214, Bergen Beach, 11234, Beverley Square East, 11226, Beverley Square West, 11226, Boerum Hill, 11201,11217, Borough Park, 11219, Brighton Beach, 11235, Broadway Junction, 11233, Brooklyn Heights, 11201, Brownsville, 11212, Bushwick, 11221, Canarsie, 11236, Carroll Gardens, 11231, Caton Park, 11218, City Line, 11207, Clinton Hill, 11205, Cobble Hill, 11201, Coney Island, 11224, Crown Heights, 11225,11213, Crown Heights North, 11213, Cypress Hills, 11208, Ditmas Park, 11226, Ditmas Park West, 11226, Downtown,11201, DUMBO, 11201, Dyker Heights, 11228, East Flatbush, 11203, East New York, 11207, 11208, East Williamsburg, 11206, Farragut, 11210, Fiske Terrace, 11230, Flatbush, 11226, Flatlands, 11236, Fort Greene, 11205, Fort Hamilton, 11209, Fulton Ferry, 11201, Georgetown, 11230, Gerritsen Beach, 11229, Gowanus, 11231, Gravesend, 11223, Greenpoint, 11222, Greenwood Heights, 11232, Highland Park, 11207, Homecrest, 11239, Kensington, 11218, Mapleton, 11204, Madison, 11229, Manhattan Beach, 11234, Manhattan Terrace, 11230, Marine Park, 11234, Midwood, 11230, Midwood Park, 11210, Mill Basin, 11234, Mill Island, 11234, Navy Yard, 11205, New Lots, 11236, North Side, 11211, Northeast Flatbush, 11212, Ocean Hill, 11233, Ocean Parkway, 11230, Paerdegat Basin, 11236, Park Slope, 11215, 11217, Plum Beach, 11235, Prospect Lefferts Gardens, 11225, Prospect Heights, 11217, 11238, Prospect Park South, 11217, Red Hook, 11231, Remsen Village, 11236, Rugby, 11203, Sea Gate, 11224, Sheepshead Bay, 11235, South Midwood, 11210, South Side, 11210, South Park Slope, 11215, Spring Creek,

11239, Stable Brooklyn, 11218, Starrett City, 11239, Stuyvesant Heights, 11216, Sunset Park, 11220, Vinegar Hill, 11201, Weeksville, 11233, West Midwood, 11230, Williamsburg, 11206,11211, Windsor Terrace, 11218, Wingate, 11203,