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The CE200 form is a crucial document for entities seeking exemption from New York State Workers’ Compensation and Disability Benefits insurance coverage. This application is specifically designed for those with no employees or for out-of-state entities whose work is entirely performed outside of New York State. It serves a dual purpose: it can be used to exempt businesses from the requirement of carrying workers’ compensation insurance and, under certain conditions, from disability benefits insurance as well. The form must be filled out completely and submitted to the New York State Workers' Compensation Board, either by fax or mail. Once processed, which may take up to four weeks, the applicant will receive a certificate of attestation of exemption. This certificate is essential for proving to government entities that the applicant is not required to carry the aforementioned insurances when applying for permits, licenses, or contracts. For immediate processing, applicants can also complete the application online, allowing them to print the certificate instantly. It is important to follow the detailed instructions provided with the form to ensure accuracy and compliance. Proper completion of the CE200 form can significantly streamline the process for businesses operating under specific conditions in New York State.
Form Sample
CE-200APPLY (4/18)
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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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Country (If other than U.S.) __________________________________________________________________
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
Homeowner 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: _____________________________________
Name: ________________________________________ Title: _____________________________________
Name: ________________________________________ Title: _____________________________________
Name: ________________________________________ Title: _____________________________________
(Attach additional sheet if necessary)
CE-200APPLY (4/18)
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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 ________________________________
CE-200APPLY (4/18)
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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
Document Specifications
| Fact Name | Description |
|---|---|
| Purpose of CE-200 Form | The CE-200 form is used to apply for a Certificate of Attestation of Exemption from New York State Workers' Compensation and/or Disability Benefits Insurance Coverage. This certificate confirms that certain entities are not required to carry these insurances. |
| Eligibility Criteria | Only entities with no employees or out-of-state entities performing all work outside of New York State can complete this application for workers' compensation exemption. For disability benefits exemption, entities must have no employees or those working in New York for less than thirty days in a calendar year. |
| Submission Process | The completed application must be submitted to the Workers' Compensation Board by mail or fax. It will be processed in the order received, and applicants can expect to receive their certificate by mail within four weeks. |
| Governing Law | This form is governed by New York State Workers' Compensation Law and New York State Disability Benefits Law, ensuring compliance with state regulations regarding insurance coverage. |
Steps to Filling Out Ce200
To successfully complete the CE-200 form, you will need to provide specific information about yourself and your business. Make sure to gather all necessary details before starting. After filling out the form, submit it to the Workers’ Compensation Board via fax or mail. Processing may take up to four weeks, so plan accordingly. If you need the certificate sooner, consider using the online application option.
- Applicant Personal Information: Fill in your first name, last name, street address, city, state, zip code, and country (if applicable). Include your personal phone number.
- Your Title: Check only one title that applies to you, such as Sole Proprietor, Treasurer, or President.
- Legal Entity Information: Provide your business's Federal ID number or your social security number if none exists. Enter the legal entity name and doing business as (DBA) name. Also, include your business phone number and email address. If the business address is the same as your personal address, check the corresponding box. If not, enter the business street address, city, state, zip code, and country.
- Permit/License/Contract Information: Indicate the nature of your business by checking one option. Specify whether you are applying for a license, permit, or contract, and provide the name of the issuing government agency.
- Job Site Location Information: If applicable, enter the job site address, city, state, zip code, and county. Provide the project dates and estimated dollar amount of the project.
- Partners/Members/Corporate Officers: List all partners or corporate officers with their titles, unless you are a sole proprietor.
- Workers’ Compensation Insurance Exemption Reason: Select the reason that your legal entity is not required to obtain New York State Workers’ Compensation Insurance Coverage.
- Disability Benefits Insurance Exemption Reason: Choose the reason that your legal entity is not required to obtain New York State Statutory Disability Benefits Insurance Coverage.
- Affirmation: Sign and date the application, affirming that the information provided is true and that you have the authority to submit the application.
More About Ce200
What is the CE-200 form and who should use it?
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 intended for entities that do not have any employees or for out-of-state entities that are applying for contracts where all work will be performed outside of New York State. Additionally, it can be used by entities without employees or those with employees working in New York State for less than thirty days in a calendar year to apply for an exemption from disability benefits insurance coverage.
How do I submit the CE-200 form?
The CE-200 form must be completed in its entirety and submitted to the New York State Workers’ Compensation Board. You can send it via fax or mail. It is important to ensure that all sections are filled out clearly and accurately. Once received, the application will be processed in the order it was submitted, and a certificate will be mailed back to you. This process can take up to four weeks. For those needing a certificate more quickly, an online application is available at www.wcb.state.ny.us, allowing for immediate printing of the certificate upon completion.
What information is required on the CE-200 form?
The CE-200 form requires several key pieces of information. Applicants must provide personal information, including their name, address, and phone number. The form also asks for details about the legal entity, such as its Federal ID number or social security number, and the nature of the business. Furthermore, applicants must indicate the type of permit, license, or contract they are applying for, along with the issuing government agency. It is crucial to review the separate instructions before completing the application to ensure all requirements are met.
What happens if the information on the CE-200 form is incorrect?
Providing incorrect information on the CE-200 form can lead to delays in processing or denial of the exemption request. It is essential to ensure that all information is accurate and truthful. The applicant must affirm the correctness of the information provided and acknowledge that any false statements could lead to legal consequences, including prosecution and civil liability. Therefore, reviewing the application carefully before submission is highly recommended.
Common mistakes
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Incomplete Information: One of the most common mistakes is failing to fill out all required fields. Every section of the CE200 form must be completed, including personal details, legal entity information, and job site location. Incomplete applications can lead to delays or rejections.
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Incorrect Title Selection: Selecting the wrong title can cause confusion about the applicant's authority. It’s essential to choose the title that accurately reflects the applicant's role within the organization. This ensures that the application is processed smoothly.
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Failure to Provide Accurate Business Information: Many applicants overlook the need to enter the correct Federal ID number or social security number. This information is crucial for verifying the legal entity's identity and ensuring compliance with state regulations.
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Neglecting to Review Instructions: Skipping the review of the CE-200 instructions can lead to misunderstandings about the application process. Taking the time to read through the instructions can help avoid common pitfalls and ensure a complete and accurate submission.
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Not Following Submission Guidelines: Some applicants fail to submit the application correctly, whether by fax or mail. It’s important to follow the specified submission method to ensure the application is received and processed in a timely manner.
Documents used along the form
The CE-200 form serves as an essential document for entities seeking an exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. Alongside the CE-200, several other forms and documents may be required to facilitate the exemption process or related administrative tasks. Below is a brief overview of these documents.
- CE-200 Instructions: This document provides detailed guidance on how to complete the CE-200 form. It outlines the necessary information required from the applicant and explains the submission process, ensuring that applicants understand their responsibilities and the implications of the exemption.
- WC-1 Form: This is the Workers' Compensation Board's application for a certificate of insurance. It is used by businesses to demonstrate that they have obtained the required workers' compensation insurance coverage. This form is essential for entities that do not qualify for an exemption.
- DB-120 Form: This form is used to apply for New York State Disability Benefits coverage. Entities that do not qualify for exemption under the Disability Benefits Law must complete this form to ensure compliance with state regulations regarding employee disability coverage.
- Business Registration Form: This document is often required to register a business entity with the state. It includes information about the business structure, ownership, and operational details. This form is crucial for establishing the legal status of the business seeking an exemption.
Each of these documents plays a vital role in the compliance landscape for businesses operating in New York State. Understanding their purposes and requirements can significantly streamline the process of obtaining necessary exemptions and maintaining regulatory compliance.
Similar forms
The CE-200 form is similar to the Certificate of Exemption from Workers' Compensation Insurance (C-105.2) in that both documents serve to exempt certain entities from the requirement of carrying workers' compensation insurance. The C-105.2 is typically used by employers who have employees but are seeking to prove their exemption status under specific conditions. Like the CE-200, it requires detailed information about the business and its operations. Both forms are aimed at ensuring compliance with state regulations while allowing eligible entities to operate without the financial burden of insurance coverage that they are not required to obtain.
Another document that shares similarities with the CE-200 is the Application for Disability Benefits Exemption (DB-120). This form is used by businesses to apply for an exemption from the New York State Disability Benefits Law. Similar to the CE-200, the DB-120 requires the applicant to provide personal and business information, as well as the reason for the exemption. Both documents are designed to protect businesses from unnecessary insurance costs while ensuring that they meet legal obligations when applying for permits or contracts.
The CE-200 form is also akin to the New York State Workers' Compensation Insurance Coverage Waiver (C-105.1). This waiver allows certain businesses, particularly those with no employees, to declare that they are not required to carry workers' compensation insurance. The C-105.1 is often used in conjunction with contracts or permits, just like the CE-200. Both forms require the applicant to affirm their status and provide necessary information about their business operations to comply with state laws.
Lastly, the CE-200 is comparable to the New York State Department of Labor Exemption Certificate (LD-1). This document is used by employers to certify that they are exempt from certain labor laws, including those related to workers' compensation. The LD-1 requires similar applicant information and is utilized when applying for permits or licenses. Both the CE-200 and LD-1 are essential for businesses seeking to navigate regulatory requirements while minimizing their insurance obligations.
Dos and Don'ts
When filling out the CE-200 form, there are important dos and don’ts to keep in mind. Following these guidelines can help ensure your application is processed smoothly.
- Do read the instructions carefully before starting the application.
- Do print clearly to avoid any misunderstandings.
- Do provide accurate personal and business information.
- Do sign the application to confirm the information is true.
- Do submit the form by fax or mail as instructed.
- Don’t leave any sections blank; complete the application in its entirety.
- Don’t have someone else fill out the application on your behalf.
- Don’t submit false information, as it can lead to serious consequences.
- Don’t forget to check if your business address is the same as your personal address.
- Don’t apply if you don’t meet the eligibility criteria for exemption.
By following these tips, you can help ensure that your application for a Certificate of Attestation of Exemption is successful.
Misconceptions
Understanding the CE-200 form is crucial for those seeking exemption from New York State Workers’ Compensation and Disability Benefits Insurance. However, several misconceptions often arise regarding its purpose and requirements. Here are five common misconceptions:
- Misconception 1: The CE-200 form can be used by any business seeking exemption.
- Misconception 2: The CE-200 form guarantees immediate exemption.
- Misconception 3: The form can be submitted by anyone on behalf of the applicant.
- Misconception 4: Once the CE-200 form is submitted, no further action is required.
- Misconception 5: The CE-200 form is only for small businesses.
This is incorrect. Only entities with no employees or out-of-state entities performing all work outside of New York State can complete this application for workers’ compensation exemption. For disability benefits exemption, the entity must have no employees or only employees working in New York for less than thirty days in a calendar year.
In reality, processing the application may take up to four weeks. For those needing immediate certification, an online application is available, allowing for instant printing of the certificate upon completion.
This is not true. The applicant must have the legal authority and knowledge to file the application. An accountant or lawyer cannot submit it on behalf of a client.
While the application is processed in the order received, the applicant must ensure that all information is accurate and complete. Any discrepancies could delay processing or lead to rejection.
This form applies to a variety of entities, including sole proprietors, partnerships, and certain nonprofit organizations. Its use is not limited to small businesses but rather to those meeting specific criteria regarding employee status and business operations.
Key takeaways
Here are some key takeaways about filling out and using the CE-200 form:
- Eligibility Criteria: Only entities without employees or out-of-state entities performing all work outside of New York State can apply for a workers' compensation exemption. For disability benefits, entities with no employees or those working in New York for less than thirty days can apply.
- Application Submission: Complete the application fully and submit it to the Workers' Compensation Board via fax or mail. Expect processing to take up to four weeks.
- Online Application Option: For immediate needs, use the online application available at www.wcb.state.ny.us. Completing it online allows you to print the certificate immediately.
- Required Information: Ensure that you provide accurate personal and legal entity information, including your title, business ID, and nature of the business. Clarity is essential.
- Signature Requirement: The applicant must sign the application, affirming that all information is true. This signature confirms that the applicant has the authority to submit the application.