New York State Law requires every facility to have workers’ compensation and disability insurance or to have a CE-200 Exemption form from the New York State Workers’ Compensation Board.
Your insurance documents must be submitted with your application and payment to:
Ulster County Department of Health (Certificate Holder)
Environmental Health Services
239 Golden Hill Lane
Kingston, NY 12401-6441
Completed forms may also be faxed to (845) 340-3045.
Per NYS requirements, only the forms listed below are accepted as proof of insurance.
If your facility requires workers' compensation and disability insurance:
- For Worker's Compensation, you must provide one of the following:
- Form C-105.2 — Certificate of Workers’ Compensation Insurance (issued by your insurance carrier)
- Form U-26.3 — Certificate of Workers’ Compensation Self-Insurance (issued by the State Insurance Fund)
- Form SI-12 — Certificate of Workers’ Compensation Self-Insurance
- Form GWI-105.2 — Certificate of Participation in Workers' Compensation Group Self-Insurance
- For Disability Benefits, you must provide one of the following:
- DB-120.1—Certificate of Disability Benefits (issued by your insurance carrier)
- DB-155 —Certificate of Disability Benefits Self-Insurance
If your facility is exempt:
If your facility has no employees, you may be eligible for an exemption. To qualify, you must obtain a signed CE-200 Exemption from the New York State Workers’ Compensation Board.
Request a CE-200