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. Fidelity Account Number of Insured 3. Address of Insurance Agent (if different from Address given on Application for Insurance) 4. Signature of Insurance Agent 1c (required) 2. Name of Employer (required if no Employer Identification Number is on the insurance policy to be approved) 3. Name of Employer (required if Employer Identification Number is on the insurance policy to be approved) 4. State of Birth of Insured 5. If Employer Identification Number is on the insurance policy being approved, State of Birth (required). a. The first name and mailing address of the Insurance Agent; and b. A description of the nature of your insurance coverage, including (1) name of coverage; (2) insured or insured persons; and (3) location of coverage; CASE #1 (REVERSE ADDRESS). The INS agent approved the Insured Employer Certificate of NYS Insured Status certificate. However, the INS agent did not receive a Copy of the NYS Insurance Agent's Registration Number, or a Form of Business Occupation Tax Certificate. CASE #2 (REVERSE ADDRESS). The INS agent approved the Insured Employer Certificate of NYS Insured Status certificate. INS agents are required to obtain those items and to report the details of the certificate to the Bureau of Workers' Compensation in accordance with Section 2.9 of the NYS Department of Labor regulations. However, the INS agent did not receive the following items: 1. Federal Employer Identification Number of the Insured Person; or 2. Name of Insured Person; CASE #3 (REVERSE ADDRESS). After reviewing the INS agent's Report of Insured Status Certificate, the Bureau of Workers' Compensation did not approve the Insured Employee Certificate of NYS Insured Status certificate. A. The INS agent approved the Insured Employee Certificate of NYS Insured Status certificate. B. The INS agent failed to obtain one of the items listed above, or both, and failed to report the facts in the Report of Insured Status Certificate in accordance with Section 2.9 of the NYS Department of Labor regulations. 4. INS Agent's Information and Disclosure File Required. The INS agent must maintain their own record of all insurance approvals, reports of losses, and records of the Insured or Insured Person's status from all jobs or employment for a minimum of two years from the date of approval of

Who needs a ? 105.2 Form?

A Certificate of NYS Workers Compensation Insurance Coverage is required to be issued by entities that issue NY workers’ compensation insurance policies to businesses, particularly these are all private carriers and their licensed insurance agents.

What is the Certificate of NYS Workers Compensation Insurance Coverage for?

The C 105.2 form certifies that an insurance carrier has insured a business indicated in the form for workers' compensation carriers under the New York State Workers’ Compensation Law.

Is Form ?105.2 accompanied by other forms?

There isn’t a necessity to attach any supporting documents to C 105.2 Certificate.

When is the fillable NY Form ?105.2 due?

The issuance of the Certificate of NYS Workers’ Compensation Insurance Coverage does not have specified time limits. However, it should not be disregarded that form C 105.2 is valid for 12 months.

How do I fill out the Workers’ Compensation Form ?105.2?

The C 105.2 fillable has 3 itemized boxes to be completed. The information to be provided includes:

• Insured entity (legal name, work location, phone number, VEIN or SON)
• Entity requesting proof of insurance (name and address)
• Insurance carrier (name, policy number, its effective period)

Finally, the certificate must be authorized by a representative or licensed agent of insurance carrier.

Where do I send NY ?105.2 Form?

The NY C 105.2 form must be filled out the insurance carrier or its certified insurance agent and submitted with the entity that applied to become a certificate holder.

 

What is the Certificate of NYS Workers Compensation Insurance Coverage for? The C 105.2 form certifies that an insurance carrier has insured a business indicated in the form for workers' compensation carriers under the New York State Workers' Compensation Law.