Pursuant to NYS Workers’ Compensation Law the Dormitory Authority can no longer except ACORD certificates as evidence of Workers’ Compensation and/or NYS Disability.  Provided below is a complete list of forms that are acceptable.  Please call if you have any questions.

Workers’ Compensation Law Requirements
Workers’ Compensation (including occupational disease) and Employer’s Liability New York Statutory Endorsement with a minimum limit of one million Dollars ($1,000,000.00) as evidenced by ONE of the following.

1. C-105.2 (9/07 or later) – Certificate of Workers’ Compensation Insurance.  The insurance carrier will provide a completed form as evidence of in-force coverage.
2. U-26.3- Certificate of Workers’ Compensation Insurance from the State Insurance Fund.  The State Insurance Fund will provide a completed form as evidence of in-force coverage.
3. GSI-105.2 /SI-12- Certificate of Workers’ Compensation Self Insurance.  The NYS Workers’ Compensation Board’s Self Insurance Office or the contractor’s Group Self Insurance Administrator will provide a completed form.

Disability Benefits

1. DB-120.1 or DB-820/829 (5/06 or later) - Certificate of Disability Benefits. The insurance carrier will provide a completed form as evidence of in-force coverage.
2. DB-155- Certificate of Disability Self Insurance. The NYS Workers’ Compensation Board’s Self Insurance Office will provide a completed form.

Exemptions

The Dormitory Authority will no longer accept WC/DB 101 for Out of State or Foreign Employers working in New York State.  Effective September 9, 2007 this form is obsolete.

For institutions claiming exemption from providing Disability Benefits insurance as required by law:

CE-200 – Certificate of Attestation of Exemption from Workers Comp and/or Disability Benefits insurance coverage.

The Dormitory Authority will no longer accept exemptions from providing Workers’ Compensation insurance coverage (WC/DB 100).  This insurance will be required of all businesses contracting with The Authority.  One of the forms listed above as required by law must be submitted as proof of coverage.  

(A CE-200 form may be obtained at the NYS Workers Compensation website http://www.wcb.state.ny.us/content/main/forms/AllForms.jsp and can be completed in either a “Web-based Application” or a “Paper Application”.)