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Workers’ Compensation Board

WCB Information Related To Novel Coronavirus (COVID-19)

Disability Benefits Forms for Homeowners

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
CE-200 (12/08) 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 (10/17) Certificate of Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law Employers 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.

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.