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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor Eliot Spitzer

Subject No. 046-196

Revised Form C-105.2,
Certificate of NYS Workers' Compensation Insurance Coverage

Supersedes Subject No. 046-121, dated November 3, 2003

Date: July 18, 2007

Effective September 1, 2007, the New York State Workers' Compensation Board is revising Form C-105.2, Certificate of New York State Workers' Compensation Insurance Coverage.

Since Form C-105.2 is a controlled form, it is not available on the Board's web site. Workers' compensation insurance carriers, however, have been advised by a separate communication on how to obtain revised Form C-105.2.

Revised Form C-105.2 (9-07) is effective September 1, 2007. Earlier-dated versions of the form are obsolete and should no longer be issued by insurers or accepted by governmental agencies after that date.

Businesses covered by a New York State workers' compensation insurance policy (New York [NY] listed under Item 3A on the Information Page of the insurance policy) and applying for a permit, license or contract from a government entity in New York State will request that their private sector insurance company provide Form C-105.2 to that government entity as proof that the business is covered by a New York State workers' compensation insurance policy. (Only private sector insurance carriers and their licensed insurance agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it.)

Please note that the insurance carrier or its licensed insurance agent can fill out Form C-105.2 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, which will be notified in the event that the policy is canceled (e.g., Building Department, Town Hall, Room 222, Town of Clark, 347 Old Clark Road, Clark, New York 55555).


Section 57 of the Workers' Compensation Law requires the heads of all municipal and State entities to ensure that businesses applying for permits, licenses or contracts have appropriate workers' compensation insurance coverage. This requirement applies to both original issuances and renewals, and also applies whether the governmental agency is having the work done or is simply issuing the permit, license or contract. This law specifically states that the proof of coverage must be submitted by insurance carriers on forms promulgated by the Chair of the New York State Workers' Compensation Board. Please note that ACORD forms are NOT acceptable proof of New York State workers' compensation insurance coverage.

Ensuring that businesses receiving permits, licenses or contracts from municipal and State agencies comply with the Workers' Compensation Law protects both injured workers and employers. In addition, such oversight helps to level the playing field, by strictly enforcing the requirement that all businesses maintain mandatory insurance coverage. Insurance carrier, municipal, and State agency cooperation in enforcing Workers' Compensation Law Sections 57 and 220(8) is a critical component of encouraging business compliance.

Outline of Revisions

The revised Form C-105.2 (9-07) contains two changes:

  1. Consistent with current underwriting rules, references to demolition on the previous version of Form C-105.2 (12-03) have been deleted.
  2. The period for which Form C-105.2 is valid has been revised to: one year after Form C-105.2 is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed on Form C-105.2, whichever is earlier.

If you have any questions regarding this process, please contact Steve Carbone from the Bureau of Compliance at 518-486-6307.


Donna Ferrara