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STATE OF NEW YORK WORKERS COMPENSATION BOARD CERTIFICATE OF NYS WORKERS COMPENSATION INSURANCE COVERAGE 1a. Legal Name & Address of Insured (Use street address only) 1b. Business Telephone Number

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How to fill out c105 2

How to fill out NY C-105.2

01

Obtain the NY C-105.2 form from the New York State Workers' Compensation Board website or your employer.

02

Fill out the employee's information section, including your name, address, and Social Security number.

03

Provide details about your employer, including their name, address, and Workers' Compensation insurance policy number.

04

Indicate the type of claims you are submitting: if it involves an injury, specify the nature of the injury and the date it occurred.

05

Provide your job title and a brief description of your job duties.

06

If applicable, include information about any prior injuries or claims.

07

Sign and date the form at the bottom.

08

Submit the completed form to your employer within the required time frame.

Who needs NY C-105.2?

01

Employees who have been injured at work and need to file for Workers' Compensation benefits in New York.

Who needs a ? 105.2 Form?
What is the Certificate of NYS Workers Compensation Insurance Coverage for?
Is Form ?105.2 accompanied by other forms?

Who needs a ? 105.2 Form?

A Certificate of NYS Workers Compensation Insurance Coverage is required to be issued by entities that issue NY workers’ compensation insurance policies to businesses, particularly these are all private carriers and their licensed insurance agents.

What is the Certificate of NYS Workers Compensation Insurance Coverage for?

The C 105.2 form certifies that an insurance carrier has insured a business indicated in the form for workers' compensation carriers under the New York State Workers’ Compensation Law.

Is Form ?105.2 accompanied by other forms?

There isn’t a necessity to attach any supporting documents to C 105.2 Certificate.

When is the fillable NY Form ?105.2 due?

The issuance of the Certificate of NYS Workers’ Compensation Insurance Coverage does not have specified time limits. However, it should not be disregarded that form C 105.2 is valid for 12 months.

How do I fill out the Workers’ Compensation Form ?105.2?

The C 105.2 fillable has 3 itemized boxes to be completed. The information to be provided includes:

Insured entity (legal name, work location, phone number, VEIN or SON)
Entity requesting proof of insurance (name and address)
Insurance carrier (name, policy number, its effective period)

Finally, the certificate must be authorized by a representative or licensed agent of insurance carrier.

Where do I send NY ?105.2 Form?

The NY C 105.2 form must be filled out the insurance carrier or its certified insurance agent and submitted with the entity that applied to become a certificate holder.

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What is form c 105 2?

What is the Certificate of NYS Workers Compensation Insurance Coverage for? The C 105.2 form certifies that an insurance carrier has insured a business indicated in the form for workers' compensation carriers under the New York State Workers' Compensation Law.

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What is NY C-105.2?

NY C-105.2 is a form used in New York State for reporting worker's compensation insurance coverage.

Who is required to file NY C-105.2?

Employers in New York who have employees and are required to provide worker's compensation coverage must file NY C-105.2.

How to fill out NY C-105.2?

To fill out NY C-105.2, employers must provide information about their business, including the business name, address, and details about their worker's compensation insurance coverage.

What is the purpose of NY C-105.2?

The purpose of NY C-105.2 is to provide proof of worker's compensation insurance coverage to the New York State Workers' Compensation Board and to employees or contractors as needed.

What information must be reported on NY C-105.2?

The information that must be reported on NY C-105.2 includes the employer's name, address, insurance carrier details, policy number, and the effective dates of the coverage.

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