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Form CE-200APPLY Application for Certificate of Attestation of Exemption - New York
What Is a Certificate of Attestation of Exemption?
Form CE-200, Application for Certificate of Attestation of Exemption , is used by the entities who want to be exempted from liability to carry their workers' compensation or disability benefits insurance.
- To apply for a New York State (NYS) workers' compensation exemption, a company should not have any employees at all or must be an out-of-state organization performing all works outside of NYS;
- To apply for an NYS disability benefits exemption, a company has to be without any employees as well or can have the employees, working in NYS for less than thirty days in a calendar year.
This form was released by the New York State Workers' Compensation Board and the latest version was issued on . A fillable CE-200 Form PDF is available for download below.
Form CE-200 Instructions
The main instructions for this form may be found in the form, but a short summary may be found here:
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Applicant's personal information should be indicated, including their name, address, and phone number;
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Your Title. The applicant should check the title referred to their position in a company. It is allowed to check only one box;
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Legal entity information should be indicated in this section, including Business Federal ID number, and Legal entity name. If there is no Federal ID number of the company, a social security number of the applicant should be entered;
- Doing Business as Name. Enter the trading name of the entity on this line;
- Check the box if the business address coincides with the applicant's address. The business address should be entered if it is different only.
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Permit/License/Contract Information.
- Check the type of work the company performs from listed below. Only one type could be chosen.
- The type of license or permit the applicant is applying to should be provided, including information about the Issuing Government Agency.
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Job Site Location information. If the applicant applies for a building, electrical or plumbing permit, it is necessary to fill in this section. The Certificate of Attestation for building permits is job-specific, and the entity has to obtain a separate certificate for each building permit.
- Job Site Address. The location where the company is going to perform the work should be entered.
- Enter the dates of the project and estimate its dollar amount.
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Partners/Members/Corporate Officers. Indicate the names and titles of all the principals of the business. Limited partnerships should enter general partners only. Sole proprietors don't have to complete the section.
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The reason for a Workers' Compensation Exemption should be chosen from boxes A-J. It is allowed to select only one of the options offered. The name and number of the temporary service agency should be entered in case of checking Box I.
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The carrier and policy information should be provided in case of checking Box J.
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The reason for a Disability Benefits Exemption should be chosen from boh AG. It is possible to select only one option.
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The applicant should sign the form and indicate the date.
Download Form CE-200APPLY Application for Certificate of Attestation of Exemption - New York
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