Fillable Form Oc-403.3 - License Application printable pdf download

State of New York

WORKERS' COMPENSATION BOARD

STOCKHOLDER OF CORPORATION APPLYING FOR LICENSE TO REPRESENT SELF-INSURERS

UNDER SECTION 50 3-b or 50 3-d OF THE WORKERS' COMPENSATION LAW

If applicant corporation is a subsidiary, this form should be completed by chief executive officer of parent corporation.

If additional information is needed, call the Licensing Unit at (1-800) 664-2379.

1. Name of applicant corporation__________________________________________________________

2. Name of stockholder_________________________________________________________________

Address___________________________________________________________________________

3. Stockholder's Social Security No._________________ Federal Employer ID No. __________________

See Privacy Notification below. If you have neither number, explain: __________________________

__________________________________________________________________________________

4. Specify percentage of stock owned______________________________________________________

5. Have you (or if a corporation, the corporation or any of the officers thereof) ever been convicted of a

crime? q Yes

q No

If Yes, state when and give details: _________________________________

__________________________________________________________________________________

Are there any criminal charges now pending against you (or if a corporation, against the corporation or

any of the officers thereof)? q Yes

q No If Yes, give details: _____________________________

__________________________________________________________________________________

6. Do you own stock in any corporation which to your knowledge has been granted self-insurer's status

under the New York State Workers' Compensation Law? q Yes

q No If Yes, give details: ________

__________________________________________________________________________________

7. Do you own stock in any corporation (other than applicant corporation) licensed or authorized to

write workers' compensation insurance in New York State? q Yes

q No

If Yes, give details: _____

__________________________________________________________________________________

_______________________________________________

Signature of Stockholder of Corporation

(or Chief Executive Officer of Parent Corporation*)

* If application is signed by other than chief executive officer of parent corporation, attach a copy of

corporate resolution delegating the authority to sign on behalf of the signing officer.

PRIVACY NOTIFICATION

The authority to request personal information from you, including identifying numbers such as Federal Social Security and

Federal Employer Identification Numbers, and the authority to maintain such information, is found in Section 5 of the Tax Law.

Disclosure of this information by you is mandatory. The principal purpose for which this information is collected is to enable the

Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns

or may have understated their tax liabilities and to generally identify persons affected by the taxes administered by the

Commissioner of Taxation and Finance. The information will be used for tax administration purposes and for any other purpose

authorized by the Tax Law or the Workers' Compensation Law.

The information collected will be held by the Office of the Secretary, Workers' Compensation Board. All inquiries regarding such

records should be addressed to the Privacy Compliance Officer, Office of the General Counsel, Workers' Compensation Board,

328 State Street, Schenectady, NY 12305. Phone: (518) 486-9564.

OC-403.3 (2-12)

Form Oc-403.3 - License Application

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