Form CE-200APPLY Application for Certificate of Attestation of Exemption - New York

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.

Download Form CE-200APPLY Application for Certificate of Attestation of Exemption - New York

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