Skip to Content

Site Navigation

WCB Home Page
Change Font Size
Glossary of WCB Terms

Obtaining a DB-120.1
Certificate of NYS Disability Benefits Insurance


Businesses covered by a statutory NYS disability benefits insurance policy and applying for a permit, license or contract from a government entity in NYS will request that their insurer provide a DB-120.1 form to that government entity as proof that the business is covered by a New York State disability benefits insurance policy. Only insurance carriers licensed to write NYS disability benefits insurance policies and their licensed NYS agents are authorized to issue the DB-120.1 form. Insurance brokers are NOT authorized to issue it.

How to Obtain Form DB-120.1

If you are an insurance carrier licensed to write statutory NYS disability benefits insurance policies, please send an e-mail to Certificates@wcb.ny.gov and indicate who you are, your position within the insurance carrier, and the specific insurance carrier that has the NYS disability benefits insurance policy that is issuing the DB-120.1 form.

If you are a licensed insurance AGENT that is authorized to write NYS disability benefits insurance policies please send an e-mail to Certificates@wcb.ny.gov and indicate who you are, your AGENT license number (including the letters in front of your license number), and the specific insurance carrier that issued the NYS disability benefits insurance policy.

If you are not an insurance carrier or one of their licensed agents with binding authority to underwrite statutory NYS disability benefits insurance policies, then your client should check with their NYS disability benefits insurance carrier for this form.