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Glossary of WCB Terms

Disability Benefits Forms for Homeowners

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader Link to External Website which is available as a free download from Adobe's web site.

After the form opens in your browser, you may complete the form by typing information on the form before you print it.

IMPORTANT: Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.

If you require assistance with completing these forms, please contact your local WCB District Office.

Form Number /
Version Date
Form Title Who Files Where to File When to File
BP-1 (12/08) Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence Homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence who are serving as their own general contractor on small jobs that require a building permit may be eligible to fill out this form as proof that they do not need a statutory workers' compensation policy (See BP-1 Cover Letter) Generally, the homeowner will file the BP-1 form with a municipal building department When the homeowner is listed as the general contractor on a building permit and is in the process of obtaining that building permit
CE-200 (12/08)

(Replaces WC/DB-100 and Form C-105.21)
Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage Applicants for permits, licenses or contracts from State, county or municipal agencies in New York State that are not required to carry NYS workers' compensation and/or disability benefits insurance coverage. Please file with the government agency that is issuing the permit, license or contract. (Examples: The New York City Department of Buildings or the New York State Department of Health) These exemption forms can ONLY be used to attest to a government entity that an applicant requesting a permit, license or contract from that government entity is not required to carry NYS workers' compensation and/or disability benefits insurance. (Instructions)
DB-120.1 (12/13) Certificate Of Insurance Coverage Under The NYS Disability Benefits Law Employers insured for NYS statutory disability benefits insurance through an insurance carrier. Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The DB-120.1 must be completed by either the NYS statutory disability benefits insurance carrier, or a licensed NYS insurance agent of that carrier. Employers must obtain this form from either their NYS statutory disability benefits insurance carrier or a licensed NYS insurance agent of that carrier.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
WC/DB-100 (9/07)
(obsolete)
See Form CE-200

If the form you are looking for is not listed above, or in the list of Common Board Forms, please e-mail the Board's Forms Department.