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304
![Form CE-200APPLY "Application for Certificate of Attestation of Exemption" - New York](https://data.templateroller.com/pdf_docs_html/1999/19995/1999548/form-ce-200apply-application-for-certificate-of-attestation-of-exemption-new-york.png "Form CE-200APPLY "Application for Certificate of Attestation of Exemption" - New York")
Form CE-200APPLY "Application for Certificate of Attestation of Exemption" - New York
Size: 321 KB
6 pages
New York State entities who want to be exempted from liability to carry their workers' compensation or disability benefits insurance may use this form to apply for the exemption.
![Form WTCVol-3 "World Trade Center Volunteer's Claim for Compensation" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279069/form-wtcvol-3-world-trade-center-volunteer-s-claim-for-compensation-new-york.png "Form WTCVol-3 "World Trade Center Volunteer's Claim for Compensation" - New York")
![Form DD-1 "Direct Deposit Authorization Form - Sample" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279041/form-dd-1-direct-deposit-authorization-form-sample-new-york.png "Form DD-1 "Direct Deposit Authorization Form - Sample" - New York")
![Form C-4 "Doctor's Initial Report" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279053/form-c-4-doctor-s-initial-report-new-york.png "Form C-4 "Doctor's Initial Report" - New York")
![Form OT/PT-4 "Occupational/ Physical Therapist's Report" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279066/form-ot-pt-4-occupational-physical-therapist-s-report-new-york.png "Form OT/PT-4 "Occupational/ Physical Therapist's Report" - New York")
![Form IME-7 "Statement of Registration" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279063/form-ime-7-statement-of-registration-new-york.png "Form IME-7 "Statement of Registration" - New York")
![Form HP-1 "Request for Decision on Unpaid Medical Bill(S)" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279061/form-hp-1-request-for-decision-on-unpaid-medical-bill-s-new-york.png "Form HP-1 "Request for Decision on Unpaid Medical Bill(S)" - New York")
![Form C-3 "Employee Claim" - New York (Haitian Creole)](https://data.templateroller.com/pdf_docs_html/2033/20336/2033625/form-c-3-0-employee-claim-new-york-haitian-creole.png "Form C-3 "Employee Claim" - New York (Haitian Creole)")
![Formulario C-3 "Reclamo Del Empleado" - New York (Spanish)](https://data.templateroller.com/pdf_docs_html/2033/20336/2033620/formulario-c-3-reclamo-del-empleado-new-york-spanish.png "Formulario C-3 "Reclamo Del Empleado" - New York (Spanish)")
![Form LAC-1 "Access to Services in Your Language: Complaint Form" - New York](https://data.templateroller.com/pdf_docs_html/1880/18809/1880941/form-lac-1-access-to-services-in-your-language-complaint-form-new-york.png "Form LAC-1 "Access to Services in Your Language: Complaint Form" - New York")
![Form MR/IME-1 "Health Provider's Application for Authorization Under the Workers' Compensation Law" - New York](https://data.templateroller.com/pdf_docs_html/1880/18809/1880940/form-mr-ime-1-health-provider-s-application-for-authorization-under-the-workers-compensation-law-new-york.png "Form MR/IME-1 "Health Provider's Application for Authorization Under the Workers' Compensation Law" - New York")
![Form HIMP-1 "New York State Workers' Compensation Board Health Insurance Matching Program" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881128/form-himp-1-new-york-state-workers-compensation-board-health-insurance-matching-program-new-york.png "Form HIMP-1 "New York State Workers' Compensation Board Health Insurance Matching Program" - New York")
![Form IME-5 "Claimant's Notice of Independent Medical Examination" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881131/form-ime-5-claimant-s-notice-of-independent-medical-examination-new-york.png "Form IME-5 "Claimant's Notice of Independent Medical Examination" - New York")
![Form IME-4 "Independent Examiner's Report of Independent Medical Examination" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881132/form-ime-4-independent-examiner-s-report-of-independent-medical-examination-new-york.png "Form IME-4 "Independent Examiner's Report of Independent Medical Examination" - New York")
![Form MG-1 "Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881135/form-mg-1-attending-doctor-s-request-for-optional-prior-approval-and-carrier-s-employer-s-response-new-york.png "Form MG-1 "Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response" - New York")
![Form MG-2 "Attending Doctor's Request for Approval of Variance and Carrier's Response" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881141/form-mg-2-attending-doctor-s-request-for-approval-of-variance-and-carrier-s-response-new-york.png "Form MG-2 "Attending Doctor's Request for Approval of Variance and Carrier's Response" - New York")
![Form RFA-2 "Request for Further Action by Carrier/Employer" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881155/form-rfa-2-request-for-further-action-by-carrier-employer-new-york.png "Form RFA-2 "Request for Further Action by Carrier/Employer" - New York")
![Form AFF-1 "Affidavit for Death Benefits" - New York](https://data.templateroller.com/pdf_docs_html/1863/18639/1863908/form-aff-1-affidavit-for-death-benefits-new-york.png "Form AFF-1 "Affidavit for Death Benefits" - New York")
![Form AFF-1 "Affidavit for Death Benefits" - New York (Yiddish)](https://data.templateroller.com/pdf_docs_html/2279/22790/2279009/form-aff-1-affidavit-for-death-benefits-new-york-yiddish.png "Form AFF-1 "Affidavit for Death Benefits" - New York (Yiddish)")
![Form PS-4 "Attending Psychologist's Report" - New York](https://data.templateroller.com/pdf_docs_html/2033/20336/2033647/form-ps-4-attending-psychologist-s-report-new-york.png "Form PS-4 "Attending Psychologist's Report" - New York")
![Form C-5 "Attending Ophthalmologist's Report" - New York](https://data.templateroller.com/pdf_docs_html/2033/20336/2033633/form-c-5-attending-ophthalmologist-s-report-new-york.png "Form C-5 "Attending Ophthalmologist's Report" - New York")
![Form IME-3 "Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863895/form-ime-3-independent-examiner-s-report-of-request-for-information-response-to-request-regarding-independent-medical-examination-new-york.png "Form IME-3 "Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination" - New York")
![Form IS-1 "Physician's Application for Designation as an Impartial Specialist" - New York](https://data.templateroller.com/pdf_docs_html/1863/18639/1863905/form-is-1-physician-s-application-for-designation-as-an-impartial-specialist-new-york.png "Form IS-1 "Physician's Application for Designation as an Impartial Specialist" - New York")
![Form IS-4 "Report of Impartial Specialist Examination or Record Review" - New York](https://data.templateroller.com/pdf_docs_html/1863/18639/1863909/form-is-4-report-of-impartial-specialist-examination-or-record-review-new-york.png "Form IS-4 "Report of Impartial Specialist Examination or Record Review" - New York")
![Form VDF-1 "Loss of Wage Earning Capacity Vocational Data Form" - New York (Chinese)](https://data.templateroller.com/pdf_docs_html/1863/18638/1863884/form-vdf-1-loss-of-wage-earning-capacity-vocational-data-form-new-york-chinese.png "Form VDF-1 "Loss of Wage Earning Capacity Vocational Data Form" - New York (Chinese)")
![Form DT-1 "Notice That Claimant Must Arrange for Diagnostic Tests & Examinations Through a Network Provider" - New York](https://data.templateroller.com/pdf_docs_html/2016/20164/2016431/form-dt-1-notice-that-claimant-must-arrange-for-diagnostic-tests-examinations-through-a-network-provider-new-york.png "Form DT-1 "Notice That Claimant Must Arrange for Diagnostic Tests & Examinations Through a Network Provider" - New York")
![Form VDF-1 "Loss of Wage Earning Capacity Vocational Data Form" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863883/form-vdf-1-loss-of-wage-earning-capacity-vocational-data-form-new-york.png "Form VDF-1 "Loss of Wage Earning Capacity Vocational Data Form" - New York")
![Form VAW-3 "Volunteer Ambulance Worker's Claim for Benefits" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881159/form-vaw-3-volunteer-ambulance-worker-s-claim-for-benefits-new-york.png "Form VAW-3 "Volunteer Ambulance Worker's Claim for Benefits" - New York")
![Form VF-3 "Volunteer Firefighter's Claim for Benefits" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881162/form-vf-3-volunteer-firefighter-s-claim-for-benefits-new-york.png "Form VF-3 "Volunteer Firefighter's Claim for Benefits" - New York")
![Form MR-4 "Impartial Specialist's Report of Medical Records Review" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863867/form-mr-4-impartial-specialist-s-report-of-medical-records-review-new-york.png "Form MR-4 "Impartial Specialist's Report of Medical Records Review" - New York")
![Form MD-1 "Attending Doctor's Request for Medical Authorization Determination" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863863/form-md-1-attending-doctor-s-request-for-medical-authorization-determination-new-york.png "Form MD-1 "Attending Doctor's Request for Medical Authorization Determination" - New York")
![Form ADR-1 "Report of Work-Related Injury or Occupational Disease" - New York](https://data.templateroller.com/pdf_docs_html/1863/18639/1863904/form-adr-1-report-of-work-related-injury-or-occupational-disease-new-york.png "Form ADR-1 "Report of Work-Related Injury or Occupational Disease" - New York")
![Form ADR-2 "Alternative Dispute Resolution Program Final Disposition or Settlement of Claim" - New York](https://data.templateroller.com/pdf_docs_html/1863/18639/1863907/form-adr-2-alternative-dispute-resolution-program-final-disposition-or-settlement-of-claim-new-york.png "Form ADR-2 "Alternative Dispute Resolution Program Final Disposition or Settlement of Claim" - New York")
![Form MD-3 "Carrier's/Self-insured Employer's Objection to Attending Doctor's Request for Medical Authorization Determination" - New York](https://data.templateroller.com/pdf_docs_html/1863/18637/1863757/form-md-3-carrier-s-self-insured-employer-s-objection-to-attending-doctor-s-request-for-medical-authorization-determination-new-york.png "Form MD-3 "Carrier's/Self-insured Employer's Objection to Attending Doctor's Request for Medical Authorization Determination" - New York")
![Form FCE-4 "Practitioner's Report of Functional Capacity Evaluation" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279062/form-fce-4-practitioner-s-report-of-functional-capacity-evaluation-new-york.png "Form FCE-4 "Practitioner's Report of Functional Capacity Evaluation" - New York")
![Form SI-1 "Application for Self-insurance" - New York](https://data.templateroller.com/pdf_docs_html/2279/22790/2279067/form-si-1-application-for-self-insurance-new-york.png "Form SI-1 "Application for Self-insurance" - New York")
