Common use of DISABILITY BENEFITS REQUIREMENTS Clause in Contracts

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the Firm) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm is self-insured. If the Firm is not required to carry DB Insurance 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmSubrecipient) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm Subrecipient should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Subrecipient is self-insured. If the Firm Subrecipient is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the Firm) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm is self-insured. If the Firm is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmSubrecipient) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Firm Subrecipient should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Subrecipient is self-insured. If the Firm Subrecipient is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmContractor) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm Contractor should contact their its insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Contractor is self-insured. If the Firm Contractor is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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.

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmVendor) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Firm District should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Vendor is self-insured. If the Firm District is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmConsultant) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm Consultant should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Consultant is self-insured. If the Firm Consultant is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the Firm) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm should contact their its insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm is self-insured. If the Firm is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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.

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the Firm) seeking seek- ing to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity en- tity it is entering into a contract with. The Firm should contact their its insurance agent to obtain acceptable proof of DB Insurance Insur- ance Coverage: • Form DB-120.1 – ““ –Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – ““ –Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the WorkersWorkers ’ Compensation Board if the Firm is self-insured. If the Firm is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption Ex- emption” from New York State Workers’ Workers ’Compensation and/or Disability Benefits Insurance Coverage.” . This form and the instructions for completing it are available at xxxx://xxx.xxx.xx.xxx

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmConsultant) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm Consultant should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: •  Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or •  Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Consultant is self-insured. If the Firm Consultant is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmThe Firm ) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm should contact their its insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm is self-insured. If the The Firm is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmProducer) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Firm Producer should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Producer is self-insured. If the Firm Producer is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmVillage) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm Village should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Village is self-insured. If the Firm Village is not required to carry DB Insurance 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmProducer) seeking to enter into a contract with a municipality (the XXXXX) CHHS must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Firm Producer should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Producer is self-insured. If the Firm Producer is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmDistrict) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm District should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Vendor is self-insured. If the Firm District is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmMember Agency) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm Member Agency should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Member Agency is self-insured. If the Firm Member Agency is not required to carry DB Insurance 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the FirmContractor) seeking to enter into a contract with a municipality (the XXXXXCounty) must provide one of the following forms to the municipal entity with which it is entering into a contract withcontract. The Firm Contractor should contact their insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm Contractor is self-insured. If the Firm Contractor is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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

DISABILITY BENEFITS REQUIREMENTS. To assist the State of New York and municipal entities in enforcing WCL Section 220(8), a business entity (the Firm) seeking to enter into a contract with a municipality (the XXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm should contact their its insurance agent to obtain acceptable proof of DB Insurance Coverage: • Form DB-120.1 – “Certificate of Insurance Coverage Under the NYS Disability Benefits Law” or • Form DB-155 – “Compliance with Disability Benefits Law” issued by the Self-Insurance Office of the Workers’ Compensation Board if the Firm is self-insured. If the Firm is not required to carry DB Insurance coverage, it must submit Form CE-200, “Certificate of Attestation of Exemption 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