Issue link: http://iaqnet.uberflip.com/i/636984
Applicant's name: Last: ____________________________________________ First: ___________________________ 4. Workers' Compensation Insurance (check one): I have workers' compensation coverage for the type of mold related work to be performed. (Submit a copy of one of the following forms: C-105.2, U-26.3, SI-12, or GSI-105.2)* I currently have no workers' compensation coverage because (check one): I have no employees and do not intend to hire employees. (Submit form CE-200.)* I have no employees at this time. (Submit form CE-200.)* When I do hire employees I will obtain worker compensation coverage classified for mold remediation and submit an update with the proof of coverage. You must provide proof that you have Workers' Compensation Insurance coverage or an exemption from such coverage. If you have questions about whether your business needs to obtain a New York State Workers' Compensation Insurance policy, please contact the Workers' Compensation Board, toll free, at (877) 632-4996. The New York State Department of Labor, License and Certification Unit, Building 12, Room 161A, State Campus, Albany, NY 12240 must be listed as the certificate holder. *Acceptable forms of proof of Workers' Compensation Insurance (Please submit only one with your application): • C-105.2: Certificate of Workers' Compensation Insurance • SI-12: Certificate of Workers' Compensation Self-Insurance • GSI-105.2: Certificate of Participation in Workers' Compensation Group Self-Insurance • U-26.3: State Insurance Fund's version of the C-105.2 • CE-200: Certificate of Attestation of Exemption 5. Disability Insurance (Check one): I have disability insurance coverage. You must submit a copy of your Certificate of Disability Insurance (form DB-120.1) or Certificate of Disability Self Insurance (form # DB-155) with your application. I am exempt from disability insurance coverage. You must submit a copy of your Certificate of Attestation of Exemption (CE-200) form, issued by the Workers' Compensation Board with your application. You must submit proof that you are in compliance with disability insurance coverage requirements of New York State Workers' Compensation Law Labor Law. Disability insurance is required in NYS if you are a "covered employer," i.e., if one or more of your employees is employed in NYS for a least 30 days in any calendar year; the 30 days need not be consecutive. Please call the Workers' Compensation Board's Bureau of Compliance, toll-free, at (877) 632-4996 if you have any questions. 6. Liability Insurance: A copy of my Certificate of Liability Insurance is enclosed. You must submit proof that you have $50,000 in liability insurance coverage for claims resulting from your licensed activities and operations. See New York State Labor Law Article 32, and § 932(3)(d) for more information. Page 2 of 4