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 Contractor) seeking to enter into a contract with a municipality (the UCEDA) must provide one of the following forms to the municipal entity it is entering into a contract with. The Contractor should contact 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 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 Contractor is self-insured. If the 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 ContractorSubrecipient) seeking to enter into a contract with a municipality (the UCEDACounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Contractor Subrecipient should contact its 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 Contractor 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 Contractor Subrecipient is self-insured. If the Contractor 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 Contractor) seeking to enter into a contract with a municipality (the UCEDAXXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Contractor should contact 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 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 Contractor is self-insured. If the 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 ContractorSubrecipient) seeking to enter into a contract with a municipality (the UCEDACounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withincluding a Waiver of Subrogation Endorsement. The Contractor Subrecipient should contact its 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 Contractor 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 Contractor Subrecipient is self-insured. If the Contractor 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 ContractorVendor) seeking to enter into a contract with a municipality (the UCEDACounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Contractor Vendor should contact its 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 Contractor 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 Contractor Vendor is self-insured. If the Contractor 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 ContractorProducer) seeking to enter into a contract with a municipality (contracts the UCEDA) must Owner MUST provide one ONE of the following forms to the municipal entity Owner it is entering into a contract with. The Contractor should contact 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 Contractor 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 Contractor Vendor is self-insured. If the Contractor 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 ContractorSubrecipient) seeking to enter into a contract with a municipality (the UCEDACounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withincluding a Waiver of Subrogation Endorsement. The Contractor Subrecipient should contact its 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 Contractor 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 Contractor Subrecipient is self-insured. If the Contractor 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 ContractorProducer) seeking to enter into a contract with a municipality (contracts the UCEDA) must County MUST provide one ONE of the following forms to the municipal entity County it is entering into a contract with. The Contractor should contact 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 Contractor 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 Contractor Vendor is self-insured. If the Contractor 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 ContractorProducer) seeking to enter into a contract with a municipality (the UCEDACounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Contractor Producer should contact its 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 Contractor 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 Contractor Producer is self-insured. If the Contractor 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 ContractorFirm) seeking to enter into a contract with a municipality (the UCEDA) must provide one of the following forms to the municipal entity it is entering into a contract with. The Contractor Firm should contact 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 Contractor 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 Contractor Firm is self-insured. If the Contractor 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 ContractorDistrict) seeking to enter into a contract with a municipality (the UCEDACounty) must provide one of the following forms to the municipal entity it is entering into a contract with. The Contractor District should contact its 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 Contractor 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 Contractor Vendor is self-insured. If the Contractor 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 Contractor) seeking to enter into a contract with a municipality (the UCEDACounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Contractor should contact its 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 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 Contractor is self-insured. If the 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 ContractorProducer) seeking to enter into a contract with a municipality (contracts the UCEDA) must Owner MUST provide one ONE of the following forms to the municipal entity Owner it is entering into a contract with. The Contractor should contact 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 Contractor 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 Contractor Vendor is self-insured. If the Contractor 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 ContractorProducer) seeking to enter into a contract with a municipality (the UCEDACHHS) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Contractor Producer should contact its 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 Contractor 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 Contractor Producer is self-insured. If the Contractor 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 ContractorFirm) seeking to enter into a contract with a municipality (the UCEDA) must provide one of the following forms to the municipal entity it is entering into a contract with. The Contractor Firm should contact 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 Contractor 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- Self-Insurance Office of the Workers’ Compensation Board if the Contractor Firm is self-insured. If the Contractor 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 ContractorFirm) seeking to enter into a contract with a municipality (the UCEDAXXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Contractor Firm should contact 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 Contractor 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 Contractor Firm is self-insured. If the Contractor 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 ContractorPRODUCER) seeking to enter into a contract contracts with a municipality municipalities (the UCEDAOWNER) must MUST provide one ONE of the following forms to the municipal entity (the OWNER) it is entering into a contract with. The Contractor should contact its insurance agent to obtain acceptable proof of WC coverage: •  IF THE PRODUCER IS REQUIRED TO CARRY COVERAGE AND HAS AN OUTSIDE CARRIER, submit Form C-105.2 – “Certificate of NYS Workers’ Compensation Insurance” or • Form U-26.3 – C-105.2, “Certificate of Workers’ ' Compensation Insurance.” issued by The PRODUCER’S insurance carrier will send this form to the New York OWNER at the PRODUCER’S request. PLEASE NOTE: The State Insurance Fund or • provides its own version of this Form SI-12 – (the U-26.3).  IF THE PRODUCER IS REQUIRED TO CARRY COVERAGE AND IS SELF INSURED, submit Form SI-12, “Affidavit Certifying that Certificate of Workers' Compensation has Been Secured” issued by the Self-Insurance”. The PRODUCER’S Group Self-Insurance Office of Administrator will send this form to the Workers’ Compensation Board if OWNER at the 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 Contractor is self-insuredPRODUCER’S request. If the Contractor is not required to carry WC coverage IF THE PRODUCER IS NOT REQUIRED TO CARRY COVERAGE, it must submit Form CE-200, “Certificate of Attestation of Exemption” from 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.xxxfrom the link located on the following page.