3c. Policy effective period
3d. The Proprietor, Partners or Executive Officers are
NYS WORKERS' COMPENSATION INSURANCE COVERAGE
(Print name of authorized representative or licensed agent of insurance carrier)
1a. Legal Name & Address of Insured (use street address only)
Work Location of Insured (Only required if coverage is specifically limited to
certain locations in New York State, i.e., a Wrap-Up Policy)
1b. Business Telephone Number of Insured
1c. NYS Unemployment Insurance Employer Registration Number of
1d. Federal Employer Identification Number of Insured or Social Security
3a. Name of Insurance Carrier
3b. Policy Number of Entity Listed in Box "1a"
2. Name and Address of Entity Requesting Proof of Coverage
(Entity Being Listed as the Certificate Holder)
included. (Only check box if all partners/officers included)
all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box “3" insures the business referenced above in box “1a” for workers'
compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A
on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send
this Certificate of Insurance to the entity listed above as the certificate holder in box “2".
The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this
Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy
expiration date listed in box "3c", whichever is earlier.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,
extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the
This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect.
Please Note: Upon cancellation of the workers' compensation 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 Workers' Compensation Coverage or other authorized proof that the business is complying with the
mandatory coverage requirements of the New York State Workers' Compensation Law.
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 the coverage as depicted on this form.
Telephone Number of authorized representative or licensed agent of insurance carrier:
Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT
authorized to issue it.