Form C-105.54 "Notice of Election to Provide Workers' Compensation Benefits to Participants in a Sheltered Workshop" - New York

What Is Form C-105.54?

This is a legal form that was released by the New York State Workers' Compensation Board - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 1999;
  • The latest edition provided by the New York State Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form C-105.54 by clicking the link below or browse more documents and templates provided by the New York State Workers' Compensation Board.

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Download Form C-105.54 "Notice of Election to Provide Workers' Compensation Benefits to Participants in a Sheltered Workshop" - New York

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THIS AGENCY EMPLOYS AND SERVES
STATE OF NEW YORK
PEOPLE WITH DISABILITIES WITHOUT
WORKERS' COMPENSATION BOARD
DISCRIMINATION.
NOTICE OF ELECTION TO PROVIDE WORKERS' COMPENSATION
BENEFITS TO PARTICIPANTS IN A SHELTERED WORKSHOP
To: Chairman, Workers' Compensation Board
To: (Print name and address of insurance carrier here)
TAKE NOTICE, that under the provisions of Section 33.09 of the Mental Hygiene Law, as amended by Chapter 690 of the Laws of
1989, the office or agency named hereby elects to provide workers' compensation benefits (excluding benefits provided under
Article Nine of the Workers' Compensation Law) to the participants in the sheltered workshop programs named below, with respect
to all policies issued to the office or agency by the insurance carrier named above.
Name of Office or Agency..................................................................................................................................................................
Address.............................................................................................................................................................................................
SHELTERED WORKSHOP PROGRAMS TO BE INCLUDED IN POLICY
N a m e
A d d r e s s
No. of Participants
I,................................................................................of the herein named office or agency certify that the above election to include
(Name of authorized person)
(Title)
participants in sheltered workshop programs described above was duly made at a meeting of the Board or other executive body
duly authorized by Law to take such action, and that copies of this notice have been filed this day with the Chairman, Workers'
Compensation Board and the insurance carrier named above.
Name of Office or Agency................................................................................................................................................................
By....................................................................................... Tel. No:.............................................. Date.........................................
(Signature)
Section 33.09, Subdivision (c) of the Mental Hygiene Law
"(c) The provisions of the workers' compensation law, the unemployment insurance law, and articles thirteen, nineteen, and twenty
of the labor law shall not apply to any patient in a facility with respect to his/her participation in a sheltered workshop program,
however, that participants in sheltered workshop programs operated by the office of mental health, the office of mental retardation
and developmental disabilities or voluntary agencies or institutional worker programs operated by the office of mental health shall
be eligible for workers' compensation benefits (excluding benefits provided pursuant to article nine of the workers' compensation
law) if such offices or agencies elect to provide such benefits. Sheltered workshops operated at department facilities shall be
subject to the laws and regulations applicable to sheltered workshops operated by voluntary agencies."
C-105.54 (3-99)
THIS AGENCY EMPLOYS AND SERVES
STATE OF NEW YORK
PEOPLE WITH DISABILITIES WITHOUT
WORKERS' COMPENSATION BOARD
DISCRIMINATION.
NOTICE OF ELECTION TO PROVIDE WORKERS' COMPENSATION
BENEFITS TO PARTICIPANTS IN A SHELTERED WORKSHOP
To: Chairman, Workers' Compensation Board
To: (Print name and address of insurance carrier here)
TAKE NOTICE, that under the provisions of Section 33.09 of the Mental Hygiene Law, as amended by Chapter 690 of the Laws of
1989, the office or agency named hereby elects to provide workers' compensation benefits (excluding benefits provided under
Article Nine of the Workers' Compensation Law) to the participants in the sheltered workshop programs named below, with respect
to all policies issued to the office or agency by the insurance carrier named above.
Name of Office or Agency..................................................................................................................................................................
Address.............................................................................................................................................................................................
SHELTERED WORKSHOP PROGRAMS TO BE INCLUDED IN POLICY
N a m e
A d d r e s s
No. of Participants
I,................................................................................of the herein named office or agency certify that the above election to include
(Name of authorized person)
(Title)
participants in sheltered workshop programs described above was duly made at a meeting of the Board or other executive body
duly authorized by Law to take such action, and that copies of this notice have been filed this day with the Chairman, Workers'
Compensation Board and the insurance carrier named above.
Name of Office or Agency................................................................................................................................................................
By....................................................................................... Tel. No:.............................................. Date.........................................
(Signature)
Section 33.09, Subdivision (c) of the Mental Hygiene Law
"(c) The provisions of the workers' compensation law, the unemployment insurance law, and articles thirteen, nineteen, and twenty
of the labor law shall not apply to any patient in a facility with respect to his/her participation in a sheltered workshop program,
however, that participants in sheltered workshop programs operated by the office of mental health, the office of mental retardation
and developmental disabilities or voluntary agencies or institutional worker programs operated by the office of mental health shall
be eligible for workers' compensation benefits (excluding benefits provided pursuant to article nine of the workers' compensation
law) if such offices or agencies elect to provide such benefits. Sheltered workshops operated at department facilities shall be
subject to the laws and regulations applicable to sheltered workshops operated by voluntary agencies."
C-105.54 (3-99)