The Ce200 form is the New York State Workers' Compensation Board Application for Certificate of Attestation of Exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This application is specifically designed for entities with no employees or out-of-state entities that perform all work outside of New York State. To ensure compliance and expedite the application process, it is important to fill out the form accurately and completely.
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The CE200 form is an essential document for those seeking an exemption from New York State's Workers' Compensation and Disability Benefits Insurance coverage. This application is specifically designed for entities that either have no employees or are out-of-state businesses performing all work outside of New York. For those seeking a disability benefits exemption, the criteria are slightly different, allowing for entities with employees working in New York for less than thirty days in a calendar year to apply. The primary purpose of the CE200 form is to provide a certificate of attestation of exemption, which serves as proof to government entities that the applicant is not required to carry the specified insurance. Completing the form requires careful attention to detail, as it must be filled out in its entirety and submitted to the Workers' Compensation Board via fax or mail. Processing can take up to four weeks, although an online application option is available for those needing immediate certification. This streamlined process allows applicants to print their certificate directly after submission. Before starting the application, individuals should review the accompanying instructions to ensure compliance and accuracy, as any errors could delay the exemption process.
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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Filling out the CE200 form is a straightforward process, but it requires careful attention to detail to ensure all necessary information is provided. Once completed, the form must be submitted to the Workers' Compensation Board, either by fax or mail. Processing may take up to four weeks, so it’s advisable to complete the form accurately to avoid delays.
What is the CE200 form?
The CE200 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 that do not have employees or for out-of-state entities whose work is performed entirely outside of New York State.
Who can complete the CE200 form?
This form can only be completed by entities without employees or by those with employees working in New York State for less than thirty days in a calendar year. It's important to ensure that the applicant meets these criteria before submitting the application.
How is the CE200 form submitted?
The completed CE200 form must be submitted to the Workers' Compensation Board either by fax or by mail. It is crucial to fill out the application in its entirety to avoid delays in processing.
How long does it take to process the CE200 application?
The application will be processed in the order it is received, and it may take up to four weeks to receive the Certificate of Attestation of Exemption. For those needing the certificate immediately, an online application is available on the Workers' Compensation Board's website, allowing for immediate printing of the certificate.
What information is required on the CE200 form?
Applicants must provide personal information, such as their name, address, and phone number, as well as details about their legal entity, including the Federal ID number or social security number. Additionally, the nature of the business and the specific permit, license, or contract being applied for must be clearly indicated.
Can someone else submit the CE200 form on my behalf?
No, the applicant must have the knowledge, information, and legal authority to file the application. An accountant or lawyer cannot submit the application for you. The applicant is also required to sign the certificate before it is filed with the relevant government entity.
What happens if I provide false information on the CE200 form?
Submitting false information can lead to serious consequences, including felony prosecution and civil liability under New York State Laws. It is essential to ensure that all information provided is accurate and truthful to avoid any legal repercussions.
Where can I find additional instructions for completing the CE200 form?
Separate instructions for completing the CE200 form are available and should be reviewed prior to filling out the application. These instructions provide detailed guidance to ensure that the application is completed correctly.
Filling out the CE200 form can be straightforward, but many people make common mistakes that can delay the process. One frequent error is not providing complete personal information. The form requires the applicant's first name, last name, address, and phone number. Omitting any of these details can lead to processing delays. Always double-check that all fields are filled out accurately.
Another mistake involves misunderstanding the title section. Applicants must select only one title that accurately reflects their position within the business. Choosing multiple titles or an incorrect title can cause confusion and may result in the rejection of the application. It's crucial to select the most relevant title to avoid any issues.
Many applicants also fail to provide the correct legal entity information. This section requires the business's Federal ID number or social security number if no Federal ID exists. Leaving this blank or entering incorrect information can complicate the verification process. Ensure that the legal entity name matches what is officially filed with the Department of State or County Clerk.
Additionally, applicants often overlook the permit/license/contract information. This section is vital as it specifies the nature of the business and the type of permit or license being applied for. Failing to provide this information or being vague can lead to misunderstandings about the application’s purpose. Be as specific as possible when describing the nature of the business.
Another common mistake is not selecting the correct reason for exemption from New York State Workers' Compensation Insurance Coverage. Each checkbox corresponds to specific criteria that must be met. Misunderstanding or misrepresenting the business status can lead to denial of the exemption. Carefully review the options and select the one that accurately reflects your situation.
Finally, applicants sometimes forget to sign and date the application. The signature affirms that the information provided is true and that the applicant has the authority to submit the application. Without a signature, the application cannot be processed. Always remember to sign and date the form before submission to ensure timely processing.
The CE-200 form is a crucial document for those seeking an exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance coverage. Along with this form, several other documents are often needed to complete the application process or to provide additional information. Below is a list of four commonly used forms and documents that accompany the CE-200 form.
These documents play a significant role in ensuring that the exemption application is processed smoothly. Having the correct forms ready can help avoid delays and complications in obtaining the necessary certifications.
When filling out the CE-200 form, it is important to follow certain guidelines to ensure the application is completed correctly. Here is a list of things you should and shouldn't do:
By adhering to these guidelines, you can help ensure a smoother application process and avoid unnecessary delays.
Here are nine common misconceptions about the CE-200 form, along with clarifications to help you better understand its purpose and requirements:
When filling out and using the CE-200 form, there are several important points to consider: