Acceptable Forms of NYS Workers Compensation/Disability Insurance

Workers' Compensation / Disability Insurance

 Workers’ Compensation, Employer’s Liability, and Disability Benefits meeting all New York State statutory requirements are required. If coverage is obtained from an insurance company through an insurance policy, the policy shall provide coverage for all states of operation that apply to the performance of the contract. In addition, if employees will be working on, near or over navigable waters, coverage provided under the U.S. Longshore and Harbor Workers’ Compensation Act must be included. Also, if the contract is for temporary services, or involves renting equipment with operators, the Alternate Employer Endorsement, WC 00 03 01A, must be included on the policy naming the People of the State of New York as the alternate employer.

Proof of compliance with Workers' Compensation coverage requirements:  

ACORD forms are NOT acceptable proof of workers’ compensation coverage.

In order to provide proof of compliance with the requirements of the Workers’ Compensation Law pertaining to workers’ compensation coverage, contractors shall:

1. A) Be legally exempt from obtaining workers’ compensation insurance coverage;

or

1. B) Obtain such coverage from insurance carriers;

or

1. C) Be a Board-approved self-insured employer or participate in an authorized self-insurance plan.

Contractors seeking to enter into contracts with the State of New York shall provide one of the following forms to SUNY Cortland at the time of bid submission or shortly after the opening of bids:

1. A) Form CE-200, Certificate of Attestation 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 which is available on the Workers’ Compensation Board’s website (wcb.state.ny.us );

or

1. B) Certificate of Workers’ Compensation Insurance:

1) Form C-105.2 (9/07) if coverage is provided by the contractor’s insurance carrier, contractor must request its carrier to send this form to SUNY Cortland;

or

2) Form U-26.3 if coverage is provided by the State Insurance Fund, contractor must request that the State Insurance Fund send this form to SUNY Cortland;

or

1. C) Certificate of Workers’ Compensation Self-Insurance - Form SI- 12, available from the New York State Workers’ Compensation Board’s Self-Insurance Office;

or

105. D) Certificate of Participation in Workers’ Compensation Group Self-Insurance Form-GSI-105.2, available from the contractor’s Group Self-Insurance Administrator.

Proof of compliance with Disability Benefits coverage requirements: 

In order to provide proof of compliance with the requirements of the Workers’ Compensation Law pertaining to disability benefits, contractors shall:

1. A) Be legally exempt from obtaining disability benefits coverage;

or

1. B) Obtain such coverage from insurance carriers;

or

1. C) Be a Board-approved self-insured employer.

Contractors seeking to enter into contracts with the State of New York shall provide one of the following forms to SUNY Cortland at the time of bid submission or shortly after the opening of bids:

1. A) Form CE-200, Certificate of Attestation 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 which is available on the Workers’ Compensation Board’s website (wcb.state.ny.us);

or

120. B) Form DB-120.1, Certificate of Disability Benefits Insurance. Contractor must request its business insurance carrier to send this form to SUNY Cortland;

or

1. C) Form DB-155, Certificate of Disability Benefits Self-Insurance. The Contractor must call the Board’s Self-Insurance Office at 518-402-0247 to obtain this form.

All forms must name the State University of New York, Professional Studies, Room 1131, PO Box 2000, Cortland NY 13045, as the Entity Requesting Proof of Coverage (Entity being listed as the Certificate Holder).