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.

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Form CE-200 Instructions

The main instructions for this form may be found in the form, but a short summary may be found here:

  1. Applicant's personal information should be indicated, including their name, address, and phone number;
  2. Your Title. The applicant should check the title referred to their position in a company. It is allowed to check only one box;
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. The carrier and policy information should be provided in case of checking Box J.
  9. The reason for a Disability Benefits Exemption should be chosen from boh AG. It is possible to select only one option.
  10. The applicant should sign the form and indicate the date.
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Download Form CE-200APPLY "Application for Certificate of Attestation of Exemption" - New York

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New York State Workers' Compensation Board
Application for Certificate of Attestation of Exemption
from
New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage.
For NYS workers’ compensation exemption, this application may only be completed by entities with no employees or
out-of-state entities obtaining contracts for which ALL work is performed outside of NYS. For NYS disability benefits
exemption, it may only be completed by entities without employees or those with employees, as defined by the NYS
Disability Benefits Law, working in NYS for less than thirty days in a calendar year.
A certificate of attestation of exemption can ONLY be used to attest to a government entity that the applicant requesting a
permit, license or contract from that government entity is not required to carry workers’ compensation and/or disability
benefits insurance.
The application must be completed in its entirety and submitted to the Workers’ Compensation Board by fax or mail. The
application will be processed in the order received and a certificate of attestation of exemption will be mailed to the
applicant. This process may take up to four
weeks.
To obtain a certificate immediately, please use the on-line application at www.wcb.state.ny.us. Once the application is
completed on-line, you can immediately print the certificate on your printer.
Please review the separate instructions (form CE-200 instructions) prior to completing this application. Please print
clearly.
1. Applicant Personal Information:
First Name:
____________________________ Last Name: ______________________________________
Street Address: ____________________________________________________________________________
City: ___________________________________ State: ____________________ Zip: _________________
Country (If other than U.S.) __________________________________________________________________
Personal Phone Number ( ______ ) ___________________________
2. Your Title (check only one)
Sole Proprietor
Treasurer
President
Partner
Vice President
Member
Secretary
Trustee
Homeowner
Board Member
Other (please provide title) __________________________________________________________
3. Legal Entity Information:
Business Federal ID (If none, enter social security number): _________________________________________
Legal Entity Name: _________________________________________________________________________
Doing Business As Name_____________________________________________________________________
Business Phone: ( _______ )__________________E-mail __________________________________________
Check here if business address is the same as the applicant’s personal address. If different, enter business
address below.
Business Street Address: _____________________________________________________________________
City: _________________________________ State: _____________________ Zip:_____________________
Country (If other than U.S.) __________________________________________________________________
CE-200APPLY (2/2009)
- 1 -
New York State Workers' Compensation Board
Application for Certificate of Attestation of Exemption
from
New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage.
For NYS workers’ compensation exemption, this application may only be completed by entities with no employees or
out-of-state entities obtaining contracts for which ALL work is performed outside of NYS. For NYS disability benefits
exemption, it may only be completed by entities without employees or those with employees, as defined by the NYS
Disability Benefits Law, working in NYS for less than thirty days in a calendar year.
A certificate of attestation of exemption can ONLY be used to attest to a government entity that the applicant requesting a
permit, license or contract from that government entity is not required to carry workers’ compensation and/or disability
benefits insurance.
The application must be completed in its entirety and submitted to the Workers’ Compensation Board by fax or mail. The
application will be processed in the order received and a certificate of attestation of exemption will be mailed to the
applicant. This process may take up to four
weeks.
To obtain a certificate immediately, please use the on-line application at www.wcb.state.ny.us. Once the application is
completed on-line, you can immediately print the certificate on your printer.
Please review the separate instructions (form CE-200 instructions) prior to completing this application. Please print
clearly.
1. Applicant Personal Information:
First Name:
____________________________ Last Name: ______________________________________
Street Address: ____________________________________________________________________________
City: ___________________________________ State: ____________________ Zip: _________________
Country (If other than U.S.) __________________________________________________________________
Personal Phone Number ( ______ ) ___________________________
2. Your Title (check only one)
Sole Proprietor
Treasurer
President
Partner
Vice President
Member
Secretary
Trustee
Homeowner
Board Member
Other (please provide title) __________________________________________________________
3. Legal Entity Information:
Business Federal ID (If none, enter social security number): _________________________________________
Legal Entity Name: _________________________________________________________________________
Doing Business As Name_____________________________________________________________________
Business Phone: ( _______ )__________________E-mail __________________________________________
Check here if business address is the same as the applicant’s personal address. If different, enter business
address below.
Business Street Address: _____________________________________________________________________
City: _________________________________ State: _____________________ Zip:_____________________
Country (If other than U.S.) __________________________________________________________________
CE-200APPLY (2/2009)
- 1 -
4. Permit/License/Contract Information:
A. Nature of Business:(please check only one)
Construction/Carpentry
Electrical
Demolition
Landscaping
Plumbing
Farm
Restaurant / Food Service
Trucking / Hauling
Food CartVendor
Horse Trainer/Owner
Homeowner
Hotel / Motel
Bar / Tavern
Mobile - Home Park
Other (please explain) ______________________________________________________________
B. Applying for:
License (list type) __________________________________________________________________
Permit (list type) ___________________________________________________________________
Contract with Government Agency
Issuing Government Agency: _____________________________________________________________
(e.g. New York City Building Department, Ulster County Health Department, New York State
Department of Labor, etc.)
5. Job Site Location Information: (Required if applying for a building, plumbing, or electrical permit)
A. Job Site Address
Street address________________________________________________________________________
City: _________________________ State: ___________ Zip: ________County: ________________
B. Dates of project: (mm/dd/yyyy) ___________________ to:(mm/dd/yyyy) _________________________
Estimated Dollar amount of project:
$0 - $10,000
$50,001 - $100,000
10,001- $25,000
Over $100,000
$25,001 - $50,000
6. Partners/Members/Corporate Officers -must list all with titles except for limited partnerships which
must include only general partners. Sole proprietors can skip this section.
Name: ________________________________________ Title: _____________________________________
Name: ________________________________________ Title: _____________________________________
Name: ________________________________________ Title: _____________________________________
Name: ________________________________________ Title: _____________________________________
(Attach additional sheet if necessary)
CE-200APPLY (2/2009)
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Employees of the Workers’ Compensation Board cannot assist applicants in answering questions in the
following two sections. Please contact an attorney if you have any questions regarding these sections.
7. Please select the reason that the legal entity is NOT required to obtain New York State
Specific Workers’ Compensation Insurance Coverage:
.
A
The applicant is NOT applying for a workers' compensation certificate of attestation of exemption and will show
a separate certificate of NYS workers' compensation insurance coverage.
B. The business is owned by one individual and is not a corporation. Other than the owner, there are no employees,
day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family
members) or subcontractors.
C. The business is a LLC, LLP, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a
corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed
employees, part-time employees, unpaid volunteers (including family members) or subcontractors.
D. The business is a one person owned corporation, with that individual owning all of the stock and holding all
offices of the corporation. Other than the corporate owner, there are no employees, day labor, leased employees,
borrowed employees, part-time employees, other stockholders, unpaid volunteers (including family members) or
subcontractors.
E. The business is a two person owned corporation, with those individuals owning all of the stock and holding all
offices of the corporation (each individual must hold an office and own at least one share of stock). Other than the
two corporate officers/owners, there are no employees, day labor, leased employees, borrowed employees, part-time
employees, other stockholders, unpaid volunteers (including family members) or subcontractors.
F. The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for
clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code) with no
compensated individuals providing services except for clergy providing ministerial services; and persons performing
teaching or nonmanual labor. [Manual labor includes but is not limited to such tasks as filing; carrying materials
such as pamphlets, binders, or books; cleaning such as dusting or vacuuming; playing musical instruments; moving
furniture; shoveling snow; mowing lawns; and construction of any sort.]
G. The business is a farm with less than $1,200 in payroll the preceding calendar year.
H. The applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence.
The homeowner has no employees, day labor, leased employees, borrowed employees, part-time employees or
subcontractors. The homeowner ONLY has uncompensated friends and family working on his/her residence.
I. Other than the business owner(s) and individuals obtained from a temporary service agency, there are no
employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including
family members) or subcontractors. Other than the business owner(s), all individuals providing services to the
business are obtained from a temporary service agency and that agency has covered these individuals for New York
State workers' compensation insurance. In addition, the business is owned by one individual or is a partnership
under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those
individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation,
each individual must be an officer and own at least one share of stock). A Temporary Service Agency is a business
that is classified as a temporary service agency under the business’s North American Industrial Classification
System (NAICS) code.
Temporary Service Agency
Name _________________________________________________ Phone #_______________________________
J. The out-of-state entity has no NYS employees and/or NYS subcontractors AND ALL work related to the permit,
license or contract is done outside of NYS; OR ALL employees are direct employees of a government entity outside
of New York. Please provide coverage information.
Carrier______________________________________Policy #__________________________________________
Policy start date _____________________________Policy expiration date ________________________________
CE-200APPLY (2/2009)
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8. Please select the reason that the legal entity is NOT required to obtain New York State
Statutory Disability Benefits Insurance Coverage:
A. The applicant is NOT applying for a disability benefits exemption and will show a separate certificate of NYS
statutory disability benefits insurance coverage.
B. The business MUST be either: 1) owned by one individual; OR 2) is a partnership (including LLC, LLP,
PLLP, RLLP, or LP) under the laws of New York State and is not a corporation; OR 3) is a one or two person
owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (in a two
person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a
business with no NYS location. In addition, the business does not require disability benefits coverage at this time
since it has not employed one or more individuals on at least 30 days in any calendar year in New York State.
(Independent contractors are not considered to be employees under the Disability Benefits Law.)
C. The applicant is a political subdivision that is legally exempt from providing statutory disability benefits
coverage.
D. The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for
clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code) with no
compensated individuals providing services except for executive officers, clergy, sextons, teachers or professionals.
E. The business is a farm and all employees are farm laborers.
F. The applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence.
The homeowner has not employed one or more individuals on at least 30 days in any calendar year in New York
State. (Independent contractors are not considered to be employees under the Disability Benefits Law.)
G. Other than the business owner(s) and individuals obtained from the temporary service agency, there are no other
employees. Other than the business owner(s), all individuals providing services to the business are obtained from a
temporary service agency and that agency has covered these individuals for New York State disability benefits
insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State
and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock
and holding all offices of the corporation (in a two person owned corporation, each individual must be an officer and
own at least one share of stock). A Temporary Service Agency is a business that is classified as a temporary service
agency under the business’s North American Industrial Classification System (NAICS) code.
9. I affirm that due to my position with the above-named business I have the knowledge,
information and legal authority to make this Application for Certificate of Attestation of
Exemption. I hereby affirm that the information provided above is true and that I have not
submitted any materially false statements and I make this application for a Certificate of
Attestation of Exemption under the penalties of perjury. I further affirm that I understand
that any false statement, representation, or concealment will subject me to felony
prosecution, including jail and civil liability in accordance with the Workers’
Compensation Law and all other New York State Laws.
Signature
Title
Date
CE-200APPLY (2/2009)
- 4 -
100 BROADWAY
THIS AGENCY EMPLOYS AND SERVES
and/or Disability Benefits insurance coverage.
and/or disability benefits insurance.
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
BUREAU OF COMPLIANCE
PEOPLE WITH DISABILITIES WITHOUT
DISCRIMINATION.
ALBANY. NY 12241 -0005
Attached is an application for a certificate of attestation of exemption from New York State Workers' Compensation
A certificate of attestation of exemption can ONLY be used to attest to a government entity that the applicant
requesting a permit, license or contract from that government entity is not required to carry workers' compensation
Please carefully review the instructions before completing the application.
Exemption Application Instructions:
This application must be completed in its entirety and submitted to the Workers' Compensation Board by mail or
fax. The application will be processed in the order received and a certificate of attestation of exemption will be
mailed to the applicant. This process may take up to four weeks to complete.
For those who require an exemption immediately, please access the on-line application that can be found on the
Board's website, www.wcb.state.nv.us. Click the "WCIDB Exemption" button on the Board's main webpage and
then click on "Request for WCIDB Exemption (Form CE-200)." You will be able to immediately print the certificate
of attestation of exemption after completing the on-line application.
Instructions:
1. Applicant Personal Information: Enter the name (first and last), address and phone number. The applicant must
have the knowledge, information and legal authority to file the application. An accountant or lawyer may not file
the application on behalf of a client. The applicant will also be required to sign the certificate of attestation of
exemption prior to filing it with the government entity.
2. Your title: Title refers to the position held by the applicant. Example: Sole Proprietor, Partner, Member,
President, Secretary, Treasurer.
3. Legal Entity Information: Enter Federal ID number used for tax purposes. If the entity does not have a Federal
ID number, enter your social security number. Legal Entity is the business's legally filed name with the Department
of State or County Clerk. Example: Corporation (ABC, Inc.) or LLC name ( XYZ, LLC). If this does not apply, enter
the applicant's name. Doing business as refers to trade name or the name the business is known by.
4. Permit/License/Contract Information: Nature of business refers to what type of work is being performed. Enter
the type of permit, license or contract for which you are applying. Examples: Building permit, health permit, liquor
license. Issuing Government Agency is the agency to which you will give the certificate. Examples: City of Albany,
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