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


Subject No. 046-308

Reduction of Form C-105, Notice of Compliance, to Letter Size

Date: April 15, 2009

On January 21, 2009, the Board issued Subject No. 046-281, which announced that the Workers' Compensation Board had revised the printing specifications for its Notices of Compliance posters, Forms C-105, VF-105, VAW-105, ADR-105 and DB-120, to allow printing on regular 20 lb. white bond. Prior to this change, durable stock, such as card, ledger or index, was required. The purpose of the change was to facilitate computer preparation, printing and distribution of the prescribed posters. However, several carriers pointed out that the larger size of Form C-105 (8 ½" x 14") made it difficult to realize these benefits. In response, the Board has reduced Form C-105 to letter size (8 ½" x 11"). Forms VF-105, VAW-105, DB-120 and ADR-105 are already letter size.

Form C-105 (4-09) may be used immediately. Please note, however, that the previous legal-sized version of Form C-105 (dated 10-07) does not have to be replaced at this time, and may continue to be used and updated with Form C-105.10, Gummed Label for Use with Form C-105 Upon Renewal of Policy, until further notice.

Insurance carriers and self-insurers may obtain a sample copy of revised Form C-105 (4-09) from the Board's Forms Department by e-mail at formsdepartment@wcb.ny.gov. Include your Board-assigned carrier ID Number (W number) in your requests.

 

Zachary S. Weiss
Chair