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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor David A. Paterson

Subject No. 046-281

Change in Printing Specifications For Compliance Posters

Date: January 21, 2009

To facilitate computer preparation, printing and distribution of prescribed Notices of Compliance, the Workers' Compensation Board has revised the printing specifications for these notices. Current specifications call for carriers and self-insurers to print Forms C-105, VF-105, VAW-105, ADR-105 and DB-120 on durable stock, such as card, ledger or index. Effective immediately, regular 20lb. white bond may be used instead of the heavier stock.

All compliance posters must continue to be kept up-to-date with current contact information, insurance policy numbers and effective and termination dates. Also, the most recent versions of these posters must be used (see chart below). We believe the new flexibility allowed in printing specifications will make this requirement less burdensome both for new policies and upon policy renewal.

Form C-105.10, Gummed Label for Use with Form C-105 Upon Renewal of Policy, may also still be used to update existing posters with new policy information as long as the current version of Form C-105 is currently posted. A comparable form for disability benefits insurance carriers, Form DB-120.10 (1-09) is also now available. Like Form C-105.10, Form DB-120.10 is a small gummed or self-adhesive label to be issued by disability benefits insurance carriers to their insureds upon renewal of a DB insurance policy. Instead of issuing a new compliance poster (Form DB-120) with a new policy number and "From" and "To" effective dates, the carrier may issue this label with the renewal information and have the employer affix it over the expired policy information on the compliance poster. It is not acceptable to enter "Until Cancelled" or similar indefinite terms as the "To" date of the policy. However, with the Board's revised printing requirements for compliance posters, the issuance of a complete new poster may be a more cost-effective option for carriers than the use of the gummed label.

The following table shows the current version dates for the Board's compliance posters:


C-105 (10-07) Workers' Compensation
DB-120 (10-07) Disability Benefits
(Please note, blue paper is not required for Form DB-120.)
VF-105 (10-07) Volunteer Firefighters
VAW-105 (10-07) Volunteer Ambulance Workers
ADR-105 (10-07) Alternate Dispute Resolution


Insurance carriers and self-insurers may obtain a sample copy of any of these forms and Forms C-105.10 and DB-120.10 from the Board's Forms Department by email at Include your Board-assigned carrier ID Number (W number) in your requests.

Thank you for your cooperation.

Zachary S. Weiss