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256
![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 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 WTCVol-3 "World Trade Center Volunteer's Claim for Compensation" - New York](https://data.templateroller.com/pdf_docs_html/1881/18811/1881161/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 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 OT/PT-4 "Occupational/ Physical Therapist's Report" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863881/form-ot-pt-4-occupational-physical-therapist-s-report-new-york.png "Form OT/PT-4 "Occupational/ Physical Therapist's Report" - New York")
![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 DD-1 "Direct Deposit and Debit Card Authorization Form" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863888/form-dd-1-direct-deposit-and-debit-card-authorization-form-new-york.png "Form DD-1 "Direct Deposit and Debit Card Authorization Form" - New York")
![Form IME-7 "Statement of Registration" - New York](https://data.templateroller.com/pdf_docs_html/1863/18639/1863900/form-ime-7-statement-of-registration-new-york.png "Form IME-7 "Statement of Registration" - 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 C-2 "Employer's Report of Work-Related Injury/Illness" - New York](https://data.templateroller.com/pdf_docs_html/1999/19996/1999634/form-c-2-employer-s-report-of-work-related-injury-illness-new-york.png "Form C-2 "Employer's Report of Work-Related Injury/Illness" - New York")
![Form HP-J1 "Provider's Request for Judgment of Award, Section 54-b, Enforcement on Failure to Pay Award or Judgment" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863893/form-hp-j1-provider-s-request-for-judgment-of-award-section-54-b-enforcement-on-failure-to-pay-award-or-judgment-new-york.png "Form HP-J1 "Provider's Request for Judgment of Award, Section 54-b, Enforcement on Failure to Pay Award or Judgment" - New York")
![Form A-9 "Notice That You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim Is Disallowed, or if Agreement Pursuant to Wcl 32 Is Approved" - New York (English/Spanish)](https://data.templateroller.com/pdf_docs_html/1863/18638/1863896/form-a-9-notice-that-you-may-be-responsible-for-medical-costs-in-the-event-of-failure-to-prosecute-or-if-compensation-claim-is-disallowed-or-if-agreement-pursuant-to-wcl-32-is-approved-new-york-english-spanish.png "Form A-9 "Notice That You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim Is Disallowed, or if Agreement Pursuant to Wcl 32 Is Approved" - New York (English/Spanish)")
![Form DD-2 "Biannual Recertification to Entitlement to Benefits" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863890/form-dd-2-biannual-recertification-to-entitlement-to-benefits-new-york.png "Form DD-2 "Biannual Recertification to Entitlement to Benefits" - New York")
![Form R "Carrier's Report on Rehabilitation" - New York](https://data.templateroller.com/pdf_docs_html/1863/18637/1863759/form-r-carrier-s-report-on-rehabilitation-new-york.png "Form R "Carrier's Report on Rehabilitation" - New York")
![Form HP-4 "Notice to Chair: Health Provider's and Insurer's Withdrawal of Request for Arbitration" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863892/form-hp-4-notice-to-chair-health-provider-s-and-insurer-s-withdrawal-of-request-for-arbitration-new-york.png "Form HP-4 "Notice to Chair: Health Provider's and Insurer's Withdrawal of Request for Arbitration" - New York")
![Form HIPAA-1 "Claimant's Authorization to Disclose Health Information (Pursuant to Hipaa)" - New York](https://data.templateroller.com/pdf_docs_html/249/2493/249393/form-hipaa-1-claimant-s-authorization-to-disclose-health-information-pursuant-to-hipaa-new-york.png "Form HIPAA-1 "Claimant's Authorization to Disclose Health Information (Pursuant to Hipaa)" - New York")
![Form VAW-1 "Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863882/form-vaw-1-notice-to-liable-political-subdivision-of-volunteer-ambulance-worker-s-injury-or-death-new-york.png "Form VAW-1 "Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death" - New York")
![Form VF-1 "Notice to Liable Political Subdivision of Volunteer Firefighter's Injury or Death" - New York](https://data.templateroller.com/pdf_docs_html/1863/18638/1863887/form-vf-1-notice-to-liable-political-subdivision-of-volunteer-firefighter-s-injury-or-death-new-york.png "Form VF-1 "Notice to Liable Political Subdivision of Volunteer Firefighter's Injury or Death" - New York")
