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Get NY DB-159.1 2003-2024

Signed to Association, Union or Trustees Plan) DISABILITY BENEFITS LAW NOTICE OF TERMINATION OF EMPLOYER'S PARTICIPATION IN SELF-INSURED ASSOCIATION, UNION OR TRUSTEES PLAN Complete two copies of this form. File original with the Chair, Workers' Compensation Board, and mail a copy to the employer. NAME OF ASSOCIATION, UNION OR TRUSTEES hereby gives notice that EMPLOYER'S participation in the Disability Benefit Plan identified above is to be terminated, as indicated herein: A. EMPLOYER'S NAME .

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