Common use of ’ COMPENSATION REQUIREMENTS Clause in Contracts

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the Subrecipient) seeking to enter into a contract with a municipality (the County) must provide one of the following forms to the municipal entity with which it is entering into a contract. The Subrecipient should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient is self-insured. If the Subrecipient is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the Subrecipient) seeking to enter into a contract with a municipality (the County) must provide one of the following forms to the municipal entity with which it is entering into a contractcontract including a Waiver of Subrogation Endorsement. The Subrecipient should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient is self-insured. If the Subrecipient is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientProducer) seeking to enter into a contract with a municipality (contracts the County) must Owner MUST provide one ONE of the following forms to the municipal entity with which Owner it is entering into a contract. The Subrecipient should contact their insurance agent to obtain acceptable proof of WC coveragecontract with: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured. If the Subrecipient Producer is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientContractor) seeking to enter into a contract with a municipality (the CountyXXXXX) must provide one of the following forms to the municipal entity with which it is entering into a contractcontract with. The Subrecipient Contractor should contact their its insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Contractor is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient Contractor is self-insured. If the Subrecipient Contractor is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx.

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientVendor) seeking to enter into a contract with a municipality (the County) must provide one of the following forms to the municipal entity with which it is entering into a contract. The Subrecipient Vendor should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured. If the Subrecipient District is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientContractor) seeking to enter into a contract with a municipality (the County) must provide one of the following forms to the municipal entity with which it is entering into a contract. The Subrecipient Contractor should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Contractor is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient Contractor is self-insured. If the Subrecipient Contractor is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientProducer) seeking to enter into a contract with a municipality (contracts the County) must Owner MUST provide one ONE of the following forms to the municipal entity with which Owner it is entering into a contract. The Subrecipient should contact their insurance agent to obtain acceptable proof of WC coveragecontract with: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured. If the Subrecipient Producer is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientProducer) seeking to enter into a contract with a municipality (the CountyCHHS) must provide one of the following forms to the municipal entity with which it is entering into a contract. The Subrecipient Producer should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Producer is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient Producer is self-insured. If the Subrecipient Producer is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the Subrecipient) seeking to enter into a contract with a municipality (the County) must provide one of the following forms to the municipal entity with which it is entering into a contractcontract including a Waiver of Subrogation Endorsement. The Subrecipient should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient is self-insured. If the Subrecipient is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientProducer) seeking to enter into a contract with a municipality (the County) must provide one of the following forms to the municipal entity with which it is entering into a contract. The Subrecipient Producer should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Producer is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Producer is self-insured. If the Subrecipient Producer is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientProducer) seeking to enter into a contract with a municipality (contracts the County) must County MUST provide one ONE of the following forms to the municipal entity with which County it is entering into a contract. The Subrecipient should contact their insurance agent to obtain acceptable proof of WC coveragecontract with: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured. If the Subrecipient Producer is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientFirm) seeking to enter into a contract with a municipality (the CountyXXXXX) must provide one of the following forms to the municipal entity with which it is entering into a contractcontract with. The Subrecipient Firm should contact their its insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Firm is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient Firm is self-insured. If the Subrecipient Firm is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

’ COMPENSATION REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the SubrecipientDistrict) seeking to enter into a contract with a municipality (the County) must provide one of the following forms to the municipal entity with which it is entering into a contractcontract with. The Subrecipient District should contact their insurance agent to obtain acceptable proof of WC coverage: • Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – “Certificate of Workers’ Compensation Insurance” issued by the New York State Insurance Fund or • Form SI-12 – “Affidavit Certifying that Compensation has Been Secured” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self-Insurance” issued by the Self-Insurance administrator of the group or • Form GSI-12 – “Certificate of Group Workers’ Compensation Group Self-Insurance” issued by the Self- Insurance Office of the Workers’ Compensation Board if the Subrecipient Vendor is self-insured. If the Subrecipient District is not required to carry WC coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption” from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx