Transcription of STATE OF NEW YORK - Welcome to NYC.gov
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STATE OF NEW YORK - Welcome to NYC.gov
SAMPLESTATE OF NEW york WORKERS COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a. Legal Name and Address of Insured (Use street address only) Grantee Organization Street Address City, STATE Zip1b. Business Telephone Number of Insured 1c. NYS Unemployment Insurance Employer Registration Number of Insured 123451d. Federal Employer Identification Number of Insured or Social Security Number and Address of the Entity Requesting Proof ofCoverage (Entity Being Listed as the Certificate Holder)The City of New YorkDepartment of Cultural Affairs 31 Chambers Street, 2nd Floor New york , New york 100073a. Name of Insurance Carrier 3b. Policy Number of entity listed in box 1a : ABCD1234567 3c. Policy effective period: _____ to _____ 4.
authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to
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