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Get Ny C-105.41 2004-2026
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How to fill out the NY C-105.41 online
Filling out the NY C-105.41 form online can be a straightforward process if you follow the guidance provided here. This form is essential for municipal corporations or political subdivisions to revoke the election to bring executive officers under the coverage of New York Workers' Compensation Law.
Follow the steps to complete the NY C-105.41 online.
- Click the ‘Get Form’ button to access the NY C-105.41 form and open it in a suitable online platform.
- Begin by filling in the details for the 'To' section. Enter the name and address of the insurance carrier. This section is critical because it identifies who the revocation will be communicated to.
- In the section titled 'Municipal Corporation or Political Subdivision,' write the name and address of the municipal corporation or political subdivision that is revoking the election. This information should reflect the official name as registered.
- Next, accurately describe the executive officers included in the policy. You can choose to list them by name, title, and address or provide a general description by department or group. Ensure clarity and completeness in this description to avoid confusion later.
- In the certification section, have the authorized person fill in their name and title. This affirms that the revocation was made in accordance with law, so accuracy is vital here.
- Input the date of submission and have the authorized person sign the form in the designated area. If the municipal corporation does not have a seal, select the appropriate checkbox.
- Once you have filled out all sections of the form, review all information for accuracy and completeness. Ensure that all mandatory fields are filled out adequately.
- After completing the review, you can save any changes to your document. Then download, print, or share the form as needed, and make sure to send it to the Chairman of the Workers' Compensation Board, along with copies to the concerned insurance carrier and officers.
Complete your document online today to ensure timely processing.
The C-11 form, often referred to as NY C-105.41, is an essential part of filing a workers' compensation claim in New York. It provides detailed information about the incident and the injured worker, which is vital for claim approval. Commonly, filing this form correctly determines the timeliness of obtaining necessary benefits.
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