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.
123-456-7890 67890 Acme Insurance 123-457-7890 Title. SAMPLE Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box “3" on this form is certifying that it is insuring the business referenced in box
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