Form Db-120.1 - Certificate Of Insurance Coverage Under The Nys Disability Benefits Law
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1
2STATE OF NEW YORK
WORKERS’ COMPENSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW
PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier
1b. Business Telephone Number of Insured
1a. Legal Name and Address of Insured (Use street address only)
123-456-7890
Grantee Organization
1c. NYS Unemployment Insurance Employer Registration
Number of Insured
Street Address
12345
City, State Zip
1d. Federal Employer Identification Number of Insured or
Social Security Number
67890
2. Name and Address of the Entity Requesting Proof of
3a. Name of Insurance Carrier
Acme Insurance
Coverage (Entity Being Listed as the Certificate Holder)
3b. Policy Number of entity listed in box “1a”:
The City of New York
ABCD1234567
Department of Cultural Affairs
31 Chambers Street, 2nd Floor
3c. Policy effective period:
New York, New York 10007
07/01/2016
06/30/2017
____________________ to ____________________
4. Policy covers:
a.
All of the employer’s employees eligible under the New York Disability Benefits Law
Only the following class or classes of the employer’s employees:
b.
Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and
that the named insured has NYS Disability Benefits insurance coverage as described above.
Signature
09/30/2016
By_____________________________________________________________________
Date Signed_________
____
(Signature of insurance carrier’s authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
123-457-7890
Title
Telephone Number____________________
Title__________________________________________________
IMPORTANT: If box “4a” is checked, and this form is signed by the insurance carrier’s authorized representative or NYS Licensed Insurance Agent of that
carrier, this certificate is COMPLETE. Mail it directly to the certificate holder.
If box “4b” is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed
for completion to the Workers’ Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 12207.
PART 2. To be completed by NYS Workers’ Compensation Board (Only if box “4b” of Part 1 has been checked)
State Of New York
Workers' Compensation Board
According to information maintained by the NYS Workers’ Compensation Board, the above-named employer has complied with the NYS
Disability Benefits Law with respect to all of his/her employees.
Date Signed_________________________
By___________________________________________________
(Signature of NYS Workers’ Compensation Board Employee)
Telephone Number____________________
Title__________________________________________________
Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of
Insurance brokers are NOT authorized to issue this form.
those insurance carriers are authorized to issue Form DB-120.1.
DB-120.1 (5-06)
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