Get Certificate Of Nys Workers' Compensation Insurance Coverage

Filling out the Certificate of New York State Workers’ Compensation Insurance Coverage is an essential task for ensuring compliance with workers' compensation laws. This guide provides a clear and systematic approach to completing the form online, tailored to assist users with varying levels of experience.

Follow the steps to effectively complete the form.

1. Click the ‘Get Form’ button to obtain the document and open it in your online editor.
2. In section 1a, enter the legal name and the street address of the insured. Make sure to include only the street address without any additional details.
3. In section 1b, provide the business telephone number of the insured. Ensure this is a current contact number.
4. Section 1c requires the NYS Unemployment Insurance Employer Registration Number of the insured, which is necessary for identification purposes.
5. For work locations that are specifically limited, fill in the appropriate details in the work location section. This is optional unless coverage is limited to certain locations.
6. In section 1d, enter either the Federal Employer Identification Number or the Social Security Number of the insured to further confirm identity.
7. In section 2, list the name and address of the entity that is requesting proof of coverage, which will act as the certificate holder.
8. Complete section 3a by entering the name of the insurance carrier that provides coverage for the insured.
9. In section 3b, provide the policy number associated with the coverage of the entity listed in box 1a.
10. Section 3c requires you to fill in the policy effective period, specifying the start and end dates of the coverage.
11. In section 3d, indicate if the proprietor, partners, or executive officers are included in the coverage by checking the appropriate box.
12. Finalize the form by obtaining the signature and printed name of an authorized representative or licensed agent of the insurance carrier in the designated spaces.
13. Provide the title and contact telephone number of the authorized representative or licensed agent in the respective fields.
14. Once all information has been accurately completed, users can save changes, download, print, or share the filled-out certificate.

Complete your documents online today to ensure compliance and streamline your administrative processes.