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New York State
Workers' Compensation Board

20 Park Street   Albany, New York 12207
DBIC-45

DISABILITY BENEFITS INSURANCE CONTRACT BULLETIN

Revised Prescribed Form DB-120.1, Certificate of Insurance
Coverage under the NYS Disability Benefits Law

Date: May 18, 2006

In accordance with Section 220 (8) of the NYS Disability Benefits Law, Form DB-120.1 is the prescribed form that serves as the certificate of insurance coverage under the NYS Disability Benefits Law. Form DB-120.1 has been revised effective May 18, 2006. The following revisions to the form are required to streamline and expedite the issuance of Form DB-120.1 to applicants receiving a permit, license or contract issued by a municipal, county or state agency.Carriers must issue this revised version of the DB-120.1 beginning 30 days after the date of this letter.

Disability Benefits carriers have been advised by a separate communication on how to obtain revised Form DB-120.1.

A copy of Section 220 (8) of the NYS Disability Benefits Law is printed on the back of this bulletin.

Outline of Revisions

Revised Form DB-120.1 contains three major changes.

First, the section to be completed by the employer is eliminated since insureds in many instances currently do not sign the forms or provide any input on the form.

Second, there is a box created for the "Certificate Holder", the government entity that is requesting proof of disability benefits coverage. This entity must receive Form DB-120.1 before a permit, license or contract is issued. Please note that the carrier or licensed agent can fill out the form with limited information from the insured. The insured should supply the carrier or licensed agent with the mailing address of the government entity requiring the certificate. (For example: Building Department, Town of Colonie, 347 Old Niskayuna Road - Room 200, Latham, New York 12110)

Third, Form DB-120.1 is completed by the insurance carrier or its licensed insurance agents (with final sign off by the NYS Workers' Compensation Board if the insurance carrier is not insuring all employees pursuant to the NYS Disability Benefits Law). Licensed insurance agents are licensed by the NYS Insurance Department, and have binding authority. Allowing licensed insurance agents to complete Form DB-120.1 will maintain controls on the issuance of the form, and usually expedite the issuance of the forms since licensed insurance agents can issue these forms themselves and not rely on the insurance carrier. Please note that insurance brokers (sales people without binding authority) are never allowed to issue these forms unless they are also licensed insurance agents authorized to write NYS disability benefits insurance policies.

This Certificate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box 3c. (Please note that disability benefits insurance policies are legally active until cancelled. However, disability benefit policies are written for a specific period of time (e.g., 1/1/05 to 1/1/06). Accordingly, that is the time period that should be included in the policy period.)

Additional Information ONLY for Carriers using DB-120.1 Certificate Validation Processes

Certain carriers have requested space on the form for their certificate validation process. Space is available for this purpose on either the back of the form (below Paragraph b of Section 220 Subd. 8) or in certain circumstances on the front of the form. If a DB carrier only writes DB policies where it is covering all employees of an employer, there is some extra space under Item 4b that may be unnecessary. The carrier may choose to transfer some of this dead space to the bottom of the front page and put the certificate verification information there. Either format is acceptable.

Please contact Steve Carbone from the Board's Bureau of Compliance at 518-486-6307 if you have any questions or require any additional information.

Thank you for your continued cooperation.

NYS Disability Benefits Law 220 Subd. 8

(a) 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 employment as defined in this article, and not withstanding 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 the payment of disability benefits for all employees has been secured as provided by this article. 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 disability benefits to any such employee if so employed.

(b) 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 employment as defined in this article, and 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 the payment of disability benefits for all employees has been secured as provided by this article.