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Form Db-120.1 - Certificate Of Insurance Coverage Under The Nys Disability Benefits Law Page 2

Additional Instructions for Form DB-120.1

By signing this form, the insurance carrier identified in box “3" on this form is certifying that it is insuring the business referenced in box

“1a” for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this

Certificate of Insurance to the entity listed as the certificate holder in box “2". This Certificate is valid for the earlier of one year after this

form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box “3c".

Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or

contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other

authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law.

DISABILITY BENEFITS LAW

§220. Subd. 8

(a) The head of a state or municipal department, board, commission or office authorized or required by law to

issue any permit for or in connection with any work involving the employment of employees in employment as

defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such

permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form

satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by

this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or

municipal department, board, commission or office to pay any disability benefits to any such employee if so

employed.

(b) The head of a state or municipal department, board, commission or office authorized or required by law to

enter into any contract for or in connection with any work involving the employment of employees in employment

as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such

contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a

form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided

by this article.

DB-120.1 (5-06) Reverse

Form Db-120.1 - Certificate Of Insurance Coverage Under The Nys Disability Benefits Law Page 2

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