PRODUCER COPY
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
PART 1
1a. Legal Name and address of Insured (Use street address only)
1ab. Work Location of Insured
(Only required if coverage is specifically limited to certain locations in New York State, i.e. a Wrap-Up Policy)
1b. Business Telephone Number of insured
1c. NYS Unemployment Insurance Employer Registration Number of Insured
1d. Federal Employer Identification Number of Insured or Social Security Number
PART 2
2. Name and Address of the Entity Requesting Proof of Coverage
(Entity Being Listed as the Certificate Holder)
PART 3
3a. Name of Insurance Carrier
3b. Policy Number of entity listed in box "1a"
3c. Policy effective period

to
3d. The Proprietor,
Partners or Executive Officers are		 included (Only check box if all partners/officers included)
all excluded or certain partnerstofficers
excluded.
3e. Demolition is
(Definition of Demolition on Reverse)
 included
excluded

This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form. New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2".

The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail) Otherwise. This Certificate is valid for a maximum of one year after this form is approved by the insurance carrier or its licensed agent.

Please Note:
Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law.

Under penally of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form.
  Approved by:  
  Name
  Date
  Title
  Telephone Number of authorized representative or licensed agent of insurance carrier
  Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it.
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.

Definition of Demolition (Part "3" on this form)

A building wrecking or demolition is one where a building, chimney or steeple is razed, or where a floor, exterior wall or roof is removed. II the contract involves only the removal of interior walls, partitions or the facing only of any exterior wall, it is not considered demolition.

Out-of-State Companies Working in NYS – NYS Workers' Compensation and Disability Benefits Requirements for Permits, Licenses or Contracts issued by NYS Government Entities

Generally, employers must have a workers' compensation policy or a combination of policies that cover each state in which they employ permanent employees to cover on-the-job accidents and disabilities. As you are probably aware, certain insurance carriers write policies that cover multiple states. "Riders" found under sections 3A and 3C on the Information Page of the policy specify the states of coverage. In addition, the operations covered in each state are identified in attachments to the policy.

In addition to any other state's workers' compensation coverages, an out-of-state employer needs to be specifically covered for NYS workers' compensation insurance when there are "sufficient contacts" between that employer and the state. While there is no single determinative factor, any of the following criteria could be the basis for finding "sufficient contacts" requiring New York coverage:

  • a physical location within New York State;
  • $50.000 in payroll during a calendar year in New York State;
  • one or more employees (including subcontractors) with a primary work location or hired within New York State; or
  • employees (including subcontractors) working in New York Slate for more than 90 days during a calendar year.


It an out-of-state employer meets any of the above criteria, it is required to carry a New York State workers' compensation policy. When New York is listed in Item 3A on the Information Page of an employer's workers' compensation insurance policy, the employer is fully covered under the NYS Workers' Compensation Law. If insured through a private insurance carrier, the out-of-state employer must file a C-105.2 – Certificate of Workers' Compensation Insurance (the business' insurance carrier will send this form to the government entity upon request)
PLEASE NOTE:
The New York State Insurance Fund provides its own version of this form, the U-26.3. If the out-of-state employer is legally, hilly self-insured in New York State, the out-of-state employer must file a SI-12 – Certificate of Workers' Compensation Self-Insurance (the business calls the Board's Self-Insurance Office at 518-402-0247). If the out-of-state employer is participating in group self-insurance, the out-of-state employer must file a GSI-105.2 – Certificate of Participation in Worker's Compensation Group Self-Insurance (the business' Group Self-Insurance Administrator will send this form to the government entity upon request).

If an out-of-state employer does not meet any of the above criteria and has New York (NY) listed in Item 3C on the Information Page of its workers' compensation insurance policy (the Other States Insurance section), NYS specific coverage is not required and the employer may be able to use its own state's workers' compensation coverage by filing a WC/DB-101 form. [The out-of-state employer's employees will be covered under NY benefits when working in New York by having NY listed in Item 3C on the Information Page of the workers' compensation insurance policy (the Other States Insurance section)]
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