Get C105 2 Blank Form

Filling out the C105 2 Blank Form online is an essential step to prove your workers' compensation insurance coverage in New York. This guide will walk you through the process, ensuring you accurately complete each section to meet the necessary requirements.

Follow the steps to successfully complete the C105 2 Blank Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In section 1a, enter the legal name and street address of the insured. Ensure accuracy, as this information is critical for your coverage.
3. In section 1b, provide the business telephone number of the insured. This should be a current contact number.
4. Fill out section 1c with the New York State Unemployment Insurance Employer Registration Number of the insured.
5. Complete section 1d by entering either the Federal Employer Identification Number or the Social Security Number of the insured.
6. In section 2, write the name and address of the entity requesting proof of coverage; this is known as the certificate holder.
7. In section 3a, indicate the name of the insurance carrier providing the coverage.
8. Enter the policy number associated with the insurance carrier in section 3b.
9. If applicable, specify the work location of the insured in section 3c, only if coverage is limited to certain locations.
10. Fill out the policy effective period in section 3c to denote when the coverage starts and ends.
11. In section 3d, indicate whether all partners or executive officers are included in the coverage by checking the appropriate box.
12. Finalize the form by signing it in the area designated for the authorized representative or licensed agent of the insurance carrier.
13. Provide the title and date of signing in the designated areas.
14. Lastly, enter the telephone number of the signing authorized representative in the provided section.
15. Review the completed form for accuracy, then save changes, download, print, or share it as necessary.

Start filling out the C105 2 Blank Form online today to ensure compliance with New York's workers' compensation insurance requirements.