Common use of Workers‟ Compensation Requirements Clause in Contracts

Workers‟ Compensation Requirements. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the Firm) seeking to enter into a contract with a municipality (the County) 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 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 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 Firm is self-insured. If the 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

Workers‟ Compensation Requirements. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the FirmConsultant) seeking to enter into a contract with a municipality (the CountyXXXXX) 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 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 Firm Consultant is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self- 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 Firm Consultant is self-insured. If the Firm Consultant 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

Workers‟ Compensation Requirements. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the FirmThe Firm Cooperative Extension Ulster County) seeking to enter into a contract with a municipality (the CountyXXXXX) must provide one of the following forms to the municipal entity it is entering into a contract with. The Firm Cooperative Extension Ulster County 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 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 The Firm Cooperative Extension Ulster County is self-insured. If the 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

Workers‟ Compensation Requirements. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the FirmConsultant) seeking to enter into a contract with a municipality (the CountyUCEDA) 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 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 Firm Consultant is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self- 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 Firm Consultant is self-insured. If the Firm Consultant 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

Workers‟ Compensation Requirements. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the Firm) seeking to enter into a contract with a municipality (the CountyXXXXX) 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 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 Firm is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self- 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 Firm is self-insured. If the 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

Workers‟ Compensation Requirements. To assist the State of New York and municipal entities in enforcing WCL Section 57, a business entity (the Firm) seeking to enter into a contract with a municipality (the County) 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 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 Firm is self-insured or • Form GSI-105.2 – “Certificate of Participation in Workers’ Compensation Group Self- 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 Firm is self-insured. If the 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