The CE-200 form is an application for a Certificate of Attestation of Exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form is specifically designed for entities with no employees or out-of-state entities performing all work outside of New York State. If you believe you qualify for an exemption, consider filling out the form by clicking the button below.
The CE200 form is an essential document for individuals and entities seeking an exemption from New York State's Workers' Compensation and/or Disability Benefits Insurance coverage. This application is specifically designed for those who either have no employees or are out-of-state entities whose work is entirely performed outside New York State. For businesses that do have employees, the exemption for disability benefits applies only if those employees work in New York for less than thirty days in a calendar year. The CE200 form serves as a certificate of attestation of exemption, which can only be presented to government entities when applying for permits, licenses, or contracts, confirming that the applicant is not required to maintain workers' compensation or disability benefits insurance. Completing the form accurately is crucial, as it must be submitted in full to the Workers' Compensation Board via fax or mail. Upon processing, which can take up to four weeks, a certificate will be mailed to the applicant. For those in need of immediate certification, an online application is available, allowing users to print their certificate right away. It is important to follow the separate instructions provided with the form carefully, ensuring all personal and legal entity information is filled out correctly, as well as specifying the nature of the business and the reasons for exemption. This proactive approach can save time and ensure compliance with New York State regulations.
New York State Workers' Compensation Board
Application for Certificate of Attestation of Exemption
from New York State Workers’ Compensation and/or
Disability and Paid Family Leave Benefits Insurance Coverage.
For NYS workers’ compensation exemption, this application may only be completed by entities with no employees or out-of-state entities obtaining contracts for which ALL work is performed outside of NYS. For NYS disability and paid family leave benefits exemption, it may only be completed by entities without employees or those with employees, as defined by the NYS Disability and Paid Family Leave Benefits Law, working in NYS for less than thirty days in a calendar year.
A certificate of attestation of exemption can ONLY be used to attest to a government entity that the applicant requesting a permit, license or contract from that government entity is not required to carry workers’ compensation and/or disability and paid family leave benefits insurance.
The application must be completed in its entirety and submitted to the Workers’ Compensation Board by fax or mail. The application will be processed in the order received and a certificate of attestation of exemption will be mailed to the applicant. This process may take up to four weeks.
To obtain a certificate immediately, please use the on-line application at www.businessexpress.ny.gov. Once the application is completed on-line, you can immediately print the certificate on your printer.
Please review the separate instructions (form CE-200 instructions) prior to completing this application. Please print clearly.
1. Applicant Personal Information:
First Name: ____________________________ Last Name: ______________________________________
Street Address: ____________________________________________________________________________
City: ___________________________________ State: ____________________ Zip: __________________
Country (If other than U.S.) __________________________________________________________________
Personal Phone Number ( ______ ) ___________________________
2.Your Title (check only one)
Sole Proprietor
Treasurer
President
Partner
Vice President
Member
Secretary
Trustee
Homeowner
Board Member
Other (please provide title) __________________________________________________________
3.Legal Entity Information:
Business Federal ID (If none, enter social security number): _________________________________________
Legal Entity Name: _________________________________________________________________________
Doing Business As Name_____________________________________________________________________
Business Phone: ( _______ )__________________E-mail __________________________________________
Check here if business address is the same as the applicant’s personal address. If different, enter business address below.
Business Street Address: _____________________________________________________________________
City: _________________________________ State: _____________________ Zip:_____________________
CE-200APPLY (4/18)
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4.Permit/License/Contract Information:
A. Nature of Business:(please check only one)
Construction/Carpentry
Electrical
Demolition
Landscaping
Plumbing
Farm
Restaurant / Food Service
Trucking / Hauling
Food CartVendor
Horse Trainer/Owner
Hotel / Motel
Bar / Tavern
Mobile - Home Park
Other (please explain) ______________________________________________________________
B. Applying for:
License (list type) __________________________________________________________________
Permit (list type) ___________________________________________________________________
Contract with Government Agency
Issuing Government Agency: _____________________________________________________________
(e.g. New York City Building Department, Ulster County Health Department, New York State Department of Labor, etc.)
5.Job Site Location Information: (Required if applying for a building, plumbing, and electrical permit) A. Job Site Address
Street address________________________________________________________________________
City: _________________________ State: ___________ Zip: ________County: ________________
B. Dates of project: (mm/dd/yyyy) ___________________ to:(mm/dd/yyyy) _________________________
Estimated Dollar amount of project:
$0 - $10,000
$50,001 - $100,000
10,001- $25,000
Over $100,000
$25,001 - $50,000
6.Partners/Members/Corporate Officers -must list all with titles except for limited partnerships which must include only general partners. Sole proprietors can skip this section.
Name: ________________________________________
Title: _____________________________________
(Attach additional sheet if necessary)
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Employees of the Workers’ Compensation Board cannot assist applicants in answering questions in the following two sections. Please contact an attorney if you have any questions regarding these sections.
7.Please select the reason that the legal entity is NOT required to obtain New York State Specific Workers’ Compensation Insurance Coverage:
□A. The applicant is NOT applying for a workers' compensation certificate of attestation of exemption and will show a separate certificate of NYS workers' compensation insurance coverage.
□B. The business is owned by one individual and is not a corporation. Other than the owner, there are no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors.
□C. The business is a LLC, LLP, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors.
□D. The business is a one person owned corporation, with that individual owning all of the stock and holding all offices of the corporation. Other than the corporate owner, there are no employees, day labor, leased employees, borrowed employees, part-time employees, other stockholders, unpaid volunteers (including family members) or subcontractors.
□E. The business is a two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (each individual must hold an office and own at least one share of stock). Other than the two corporate officers/owners, there are no employees, day labor, leased employees, borrowed employees, part-time employees, other stockholders, unpaid volunteers (including family members) or subcontractors.
□F. The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code) with no compensated individuals providing services except for clergy providing ministerial services; and persons performing teaching or nonmanual labor. [Manual labor includes but is not limited to such tasks as filing; carrying materials such as pamphlets, binders, or books; cleaning such as dusting or vacuuming; playing musical instruments; moving furniture; shoveling snow; mowing lawns; and construction of any sort.]
□G. The business is a farm with less than $1,200 in payroll the preceding calendar year.
□H. The applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence.
□
The homeowner ONLY has uncompensated friends and family working on his/her residence or is hiring individuals a total of less than 40 aggregate hours per week and has a current homeowner’s insurance policy that covers the property.
I. Other than the business owner(s) and individuals obtained from a temporary service agency, there are no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. Other than the business owner(s), all individuals providing services to the business are obtained from a temporary service agency and that agency has covered these individuals for New York State workers' compensation insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation, each individual must be an officer and own at least one share of stock). A Temporary Service Agency is a business that is classified as a temporary service agency under the business’s North American Industrial Classification System (NAICS) code.
Temporary Service Agency
Name _________________________________________________ Phone #_______________________________
J.The out-of-state entity has no NYS employees and/or NYS subcontractors AND ALL work related to the permit, license or contract is done outside of NYS; OR ALL employees are direct employees of a government entity outside of New York. Please provide coverage information.
Carrier______________________________________Policy #__________________________________________
Policy start date _____________________________Policy expiration date ________________________________
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8.Please select the reason that the legal entity is NOT required to obtain New York State Statutory Disability and/or Paid Family Benefits Insurance Coverage:
□A. The applicant is NOT applying for a disability and paid family benefits exemption and will show a separate certificate of NYS statutory disability benefits insurance coverage.
B. The business MUST be either: 1) owned by one individual; OR 2) is a partnership (including LLC, LLP, PLLP, RLLP, or LP) under the laws of New York State and is not a corporation; OR
3)is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition, the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.)
C.The applicant is a political subdivision that is legally exempt from providing statutory disability and/or paid
family leave benefits coverage.
D. The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for
clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code) with no compensated individuals providing services except for executive officers, clergy, sextons, teachers or professionals.
□E. The business is a farm and all employees are farm laborers.
□F. The applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.)
□G. Other than the business owner(s) and individuals obtained from the temporary service agency, there are no other employees. Other than the business owner(s), all individuals providing services to the business are obtained from a temporary service agency and that agency has covered these individuals for New York State disability and paid family leave benefits insurance. In addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation, each individual must be an officer and own at least one share of stock). A Temporary Service Agency is a business that is classified as a temporary service agency under the business’s North American Industrial Classification System (NAICS) code.
9.I affirm that due to my position with the above-named business I have the knowledge, information and legal authority to make this Application for Certificate of Attestation of Exemption. I hereby affirm that the information provided above is true and that I have not submitted any materially false statements and I make this application for a Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement, representation, or concealment will subject me to felony prosecution, including jail and civil liability in accordance with the Workers’ Compensation Law and all other New York State Laws.
Signature
Title
Date
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Completing the CE-200 form is an important step in applying for a certificate of attestation of exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form needs to be filled out carefully, as it will be submitted to the Workers’ Compensation Board for processing. Once the application is complete and submitted, it may take up to four weeks for the certificate to be mailed to you.
Once you have completed all the sections, review the form to ensure accuracy. Then, submit it to the Workers’ Compensation Board by fax or mail. If you need the certificate sooner, consider using the online application option available on the Board's website.
The CE-200 form is an application for a Certificate of Attestation of Exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. It is specifically designed for entities without employees or out-of-state entities performing work entirely outside of New York State.
This application can only be completed by entities that meet certain criteria. For workers’ compensation exemption, it must be filled out by entities with no employees or out-of-state entities with contracts for work performed outside of New York. For disability benefits exemption, it can be completed by entities without employees or those with employees working in New York for less than thirty days in a calendar year.
The CE-200 form serves to attest to a government entity that the applicant is not required to carry workers’ compensation and/or disability benefits insurance. This is essential when applying for permits, licenses, or contracts from government agencies.
The completed application must be submitted to the Workers’ Compensation Board by fax or mail. It is important to ensure that the application is fully completed before submission to avoid delays in processing.
The processing time for the CE-200 form can take up to four weeks. However, applicants needing a certificate immediately can use the online application available at www.wcb.state.ny.us, where they can print the certificate right after completing the application.
The CE-200 form requires the following information:
Employees of the Workers’ Compensation Board cannot assist with completing the application. If there are questions regarding specific sections, it is advisable to consult with an attorney.
Providing false information on the CE-200 form can lead to severe consequences, including felony prosecution, jail time, and civil liability under New York State laws. It is crucial to ensure that all information provided is accurate and truthful.
Before filling out the CE-200 form, applicants should review the separate instructions provided with the form. This ensures that all requirements are met and that the application is completed correctly.
Incomplete Personal Information: Failing to provide all required personal details, such as first name, last name, or contact information, can delay the processing of the application.
Incorrect Title Selection: Selecting more than one title or failing to check any title can lead to confusion about the applicant's authority.
Missing Legal Entity Information: Not entering the correct Federal ID number or social security number can result in rejection of the application.
Neglecting Job Site Location: If applying for a permit that requires job site information, omitting this section will cause delays.
Incorrectly Identifying Employees: Misclassifying individuals as employees when they are independent contractors or volunteers can lead to compliance issues.
Failure to Sign: Not signing the application or having someone else sign it can invalidate the submission.
Ignoring Instructions: Not reviewing the specific instructions for completing the CE-200 form can lead to various mistakes and misunderstandings.
The CE200 form is essential for entities seeking an exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. Alongside this form, several other documents are often required to ensure compliance with state regulations and facilitate the exemption process. Below is a list of related forms and documents that may be used in conjunction with the CE200 form.
Each of these documents plays a vital role in the application process for exemptions and compliance with New York State regulations. Properly completing and submitting these forms can facilitate a smoother experience for applicants seeking to navigate the complexities of workers' compensation and disability benefits insurance requirements.
The Certificate of Insurance (COI) serves a similar purpose to the CE200 form by providing proof of insurance coverage. Businesses often need to present a COI when applying for permits or contracts, demonstrating that they have the necessary insurance in place. Like the CE200, the COI is typically required by government entities to ensure compliance with local regulations. The COI outlines the types of coverage held by the business and can include general liability, workers’ compensation, and more. Both documents are essential for businesses to operate legally and avoid potential liabilities.
The Business License Application is another document akin to the CE200 form. This application is necessary for businesses to legally operate within a specific jurisdiction. Similar to the CE200, it requires detailed information about the business, including ownership, type of business, and location. Government agencies use this application to ensure that businesses meet local regulations and standards. Both documents are vital for securing the right to conduct business and often involve a review process before approval is granted.
The 1099 Form is related in that it deals with the classification of workers. While the CE200 form addresses exemptions from workers' compensation and disability benefits, the 1099 Form is used to report payments made to independent contractors. Both documents are crucial for compliance with state and federal regulations. They help clarify the employment status of individuals and ensure that businesses are following the appropriate legal guidelines regarding compensation and insurance coverage.
The IRS Form W-9 is similar in its function of collecting information about the business entity. This form is used to request the taxpayer identification number of a business or individual. Just as the CE200 form collects essential information to establish an exemption from insurance requirements, the W-9 gathers necessary details for tax purposes. Both forms are critical for maintaining accurate records and ensuring compliance with legal obligations.
Finally, the Application for a Federal Employer Identification Number (EIN) shares similarities with the CE200 form. The EIN application is required for businesses that need to identify themselves for tax purposes. Like the CE200, this application demands detailed information about the business structure and ownership. Both documents are foundational for businesses, as they help establish legitimacy and are often prerequisites for obtaining other licenses or permits.
When filling out the CE-200 form, it’s essential to follow certain guidelines to ensure your application is processed smoothly. Here are four things you should and shouldn't do:
Misconception 1: The CE-200 form can be used by any business regardless of its employee status.
This is not true. The CE-200 form is specifically designed for entities with no employees or for out-of-state entities that perform all work outside of New York State. If a business has employees or is operating within New York State, it is generally required to carry workers' compensation and/or disability benefits insurance.
Misconception 2: The CE-200 form provides immediate exemption from insurance requirements.
In reality, the application process for the CE-200 form can take up to four weeks. While there is an option for immediate online application, the standard submission by mail or fax does not guarantee immediate exemption. Applicants must plan accordingly to avoid delays in obtaining necessary permits or contracts.
Misconception 3: Completing the CE-200 form is a simple task that anyone can do without assistance.
While the form may seem straightforward, it requires accurate information and specific qualifications. Applicants must have the legal authority to complete the form. Employees of the Workers' Compensation Board cannot assist with questions related to certain sections, so it is advisable to consult an attorney for clarity and guidance.
Misconception 4: Once the CE-200 form is submitted, there is no need to follow up.
This is misleading. Although the application will be processed in the order it is received, applicants should ensure that their submission is complete and accurate to avoid delays. It is also beneficial to check on the status of the application if there is a pressing timeline for obtaining permits or contracts.
When filling out and using the CE-200 form, consider the following key takeaways: