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c 105 2

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STATE OF NEW YORK WORKERS COMPENSATION BOARD CERTIFICATE OF NYS WORKERS COMPENSATION INSURANCE COVERAGE 1a. Legal Name & Address of Insured (Use street address only) 1b. Business Telephone Number
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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, FEIN or SNN)
  • 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.

 

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