Free C 105 2 PDF Form

How to Fill Out C 105 2

Filling out the C-105.2 form is a crucial step for businesses to prove they have the necessary workers' compensation insurance coverage under New York State law. This document is especially important for entities that must display proof of insurance to state or municipal departments before obtaining permits or contracting for work involving the employment of workers in hazardous jobs. Below, you'll find a straightforward, step-by-step guide that ensures the form is filled out correctly and efficiently.

1. Legal Name & Address of Insured: Enter the legal name of your business and the street address where your business is located, not a P.O. Box.
2. Business Telephone Number of Insured: Provide the main contact number for your business.
3. NYS Unemployment Insurance Employer Registration Number of Insured: Enter the registration number assigned to your business by the New York State Department of Labor for Unemployment Insurance purposes.
4. Federal Employer Identification Number (FEIN) or Social Security Number: Choose the appropriate identification number that your business uses for federal tax purposes and enter it here.
5. Work Location of Insured: Fill this section only if your workers' compensation insurance coverage is limited to specific locations within New York State. Otherwise, leave it blank.
6. Name and Address of Entity Requesting Proof of Coverage: Input the legal name and address of the entity (e.g., government department, client) that is requesting to see your proof of insurance coverage.
7. Name of Insurance Carrier: Write the full legal name of the insurance company that provides your workers' compensation insurance.
8. Policy Number: Enter the policy number as it appears on your workers' compensation insurance policy.
9. Policy Effective Period: Indicate the start and end dates of your current insurance policy’s effectiveness.
10. Proprietor, Partners or Executive Officers Inclusion: Check the relevant box to confirm if all, none, or some proprietors, partners, or executive officers are included in the workers' compensation insurance coverage.
11. Authorized Representative or Licensed Agent of the Insurance Carrier Approval: This section is for the insurance carrier or their licensed agent to complete. They will confirm the coverage details, sign, date, and provide contact information.

After the form has been filled out and signed by the authorized representative or licensed agent of the insurance carrier, it will be sent to the entity requesting proof of your insurance coverage. Remember, this certificate serves merely as evidence of coverage and does not alter or extend the coverage itself. Keep a copy for your records and be prepared to provide a new Certificate of Workers' Compensation Coverage should your current policy be canceled for any reason. Doing so ensures your business remains in compliance with New York State law.

What is the C-105.2 form?

The C-105.2 form is a Certificate of New York State Workers' Compensation Insurance Coverage. It serves as proof that a business has obtained the necessary workers' compensation insurance coverage as required by New York State law. This document contains information about the insured business, the insurance carrier, and the policy itself, including the policy number and effective dates.

Who needs to fill out the C-105.2 form?

Insurance carriers or their licensed agents must fill out and issue the C-105.2 form. It is specifically designed for businesses that are insured for workers' compensation in New York State. The form is used to provide evidence of coverage to entities requesting proof, such as for permits, licenses, or contracts that involve work in hazardous employment.

How is the C-105.2 form used?

The form is used as evidence of a workers' compensation insurance contract. It is sent by the insurance carrier or its licensed agent to the entity requesting proof of coverage, also known as the certificate holder. This form must be provided when a business seeks permits, licenses, or contracts that require proof of workers' compensation insurance under state law.

What happens if my policy is canceled?

If the workers' compensation insurance policy indicated on the C-105.2 form is canceled, the insurance carrier must notify both the certificate holder and the Workers' Compensation Board within 10 days for cancellations due to nonpayment of premiums, and within 30 days for other reasons. The business must then provide a new C-105.2 form or other authorized proof of compliance with the state's insurance requirements if it continues to be named on a permit, license, or contract issued by a certificate holder.

Can insurance brokers issue the C-105.2 form?

No, insurance brokers are not authorized to issue the C-105.2 form. Only insurance carriers and their licensed agents are permitted to issue this certificate of insurance coverage.

What information is required on the C-105.2 form?

The form requires detailed information about the insured business, such as the legal name, business address, and contact number. It also needs the business's unemployment insurance employer registration number, federal employer identification number or Social Security number for certain locations in New York State, and the specific work location if the coverage is limited. Furthermore, the form asks for the name and address of the entity requesting proof of coverage, details about the insurance carrier, and the policy number with its effective period.

Does the C-105.2 form amend or alter existing insurance coverage?

No, the C-105.2 form does not amend, extend, or alter the coverage afforded by the policy listed on it. The certificate is issued for informational purposes only and does not confer rights upon the certificate holder beyond those contained in the referenced policy.

Is the C-105.2 form valid indefinitely?

The certificate is valid for one year after it is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed on the form, whichever comes first. The validity is contingent upon the underlying policy remaining in effect.

What is the consequence of not providing a C-105.2 form when required?

Failure to provide a C-105.2 form or other authorized proof of workers' compensation insurance can result in the denial of permits, licenses, or contracts. It is crucial for businesses engaging in hazardous employment in New York State to comply with this requirement to avoid disruptions in their operations.

Where can I get a C-105.2 form?

C-105.2 forms are obtained through the Workers' Compensation Board website or directly from your workers' compensation insurance carrier or their licensed agent. Remember, insurance brokers cannot issue this form.

1. Failing to use the legal name and street address of the insured in section "1a" often leads to confusion and delays. Always ensure to use the precise legal name and physical address for clarity.

2. Overlooking the importance of the business telephone number in section "1b." Including a current and accurate phone number facilitates swift communication.

3. Not providing the New York State Unemployment Insurance Employer Registration Number in section "1c" is a common mistake. This number is crucial for identification and verification purposes.

4. Neglecting to specify the work location in section "1d" when coverage is limited to specific locations in New York State can lead to incorrect insurance application.

5. Forgetting to list the name and address of the entity requesting proof of coverage in section "2" can cause unnecessary delays. This information is vital for ensuring the correct entity receives the proof of insurance.

6. Incorrectly completing the insurance information sections (3a to 3d), such as entering the wrong insurance carrier name or policy number, can invalidate the certificate. Double-check these fields for accuracy.

7. Omitting or inaccurately stating the policy effective period in section "3c" could lead to confusion regarding the terms of coverage.

8. Failing to appropriately indicate whether the proprietor, partners, or executive officers are included or excluded from coverage in section "3d" may result in insufficient coverage or non-compliance with regulations.

Remember, it's essential to ensure all information is accurate and current to avoid any complications or lapses in coverage. Taking the time to review and verify details can save a significant amount of time and prevent issues with workers' compensation insurance coverage.

When managing workers' compensation requirements, several forms and documents complement the C-105.2 form. These documents are crucial for ensuring compliance, facilitating claims handling, and providing proof of insurance coverage. Each serves a specific purpose in the broader context of workers' compensation insurance management.

• DB-120.1: This form is a certificate of disability benefits insurance. Employers must display it prominently at their place of business. It serves as proof that the employer has obtained disability benefits insurance for their employees.
• C-240: Employers use this form to report an employee's earnings for the year prior to an injury, illness, or death. It provides the insurance carrier with necessary information to determine compensation rates.
• WCB-1: Named "Employer's First Report of Work-Related Injury/Illness," this form is used by employers to report workplace injuries to the workers' compensation board. It's a critical first step in the claim process.
• SI-12: This form is for self-insured employers, declaring their self-insurance for workers' compensation. It demonstrates compliance with state requirements without using a traditional insurance carrier.
• U-26.3: Used by state-funded employers, this form confirms state insurance fund coverage. It's similar to the C-105.2 but specific to state agencies or entities covered under the state insurance program.
• DB-155: Companies use this to prove they carry New York State disability and Paid Family Leave benefits insurance. It's similar to the C-105.2 but for disability benefits specifically.
• OC-110A: Employee Claim forms are used by employees to file a claim for workers' compensation benefits. While not directly used by employers, they are essential documents within the workers' compensation system.

Together, these forms and documents create a comprehensive framework for managing and demonstrating compliance with workers' compensation insurance requirements. Employers must familiarize themselves with these documents to ensure timely and accurate fulfillment of legal obligations, ultimately safeguarding both their employees and their business operations.

• The ACORD 25 Certificate of Liability Insurance form is similar to the C 105 2 form in that it provides a summary of coverage and serves as proof of insurance coverage to a third party, such as clients or contractors. However, it specifically relates to general liability insurance rather than workers' compensation insurance.

• The SI-12 Certificate of Workers' Compensation Self-Insurance shares similarities with the C 105 2 form by demonstrating a business's compliance with state workers' compensation laws. The SI-12 is used by businesses that self-insure their workers' compensation liabilities, showcasing their ability to cover such responsibilities without an external insurance policy.

• The U-26.3 State Insurance Fund Certificate of Workers' Compensation Insurance is alike because it also certifies workers' compensation insurance coverage for businesses. However, it is specifically issued for policies underwritten by the State Insurance Fund, differentiating it from the C 105 2 form which pertains to policies issued by private insurance carriers.

• The DB-120.1 Certificate of Disability Benefits Insurance parallels the C 105 2 form in its role of verifying insurance coverage. While the C 105 2 form focuses on workers' compensation, the DB-120.1 form pertains to disability benefits insurance, demonstrating a business’s compliance with state disability benefits insurance requirements.

• GSI-105.2 Certificate of Group Self-Insurance has similarities with the C 105 2 form, as it confirms a group's compliance with workers' compensation coverage mandates. The GSI-105.2 is exclusive to groups of employers who collectively self-insure their workers' compensation liabilities, offering a collective alternative to individual certificates of insurance like the C 105 2.

• The BWC-030 Certificate of Ohio Workers' Compensation Coverage functions similarly to the C 105 2 form by evidencing that an employer has secured workers' compensation insurance, required by state law. This form, however, is specific to Ohio, demonstrating the localized nature of workers' compensation insurance certification across different states.

When it comes to completing the C-105.2 form, which is a Certificate of NYS Workers' Compensation Insurance Coverage, there are specific practices you should follow to ensure the form is filled out accurately and effectively. Below are five dos and don'ts to consider:

• Review the form thoroughly before starting to fill it out to ensure you understand all the required information.
• Use the legal name and street address of the insured when filling out section 1a to avoid any discrepancies.
• Double-check the policy number and the policy effective period listed in section 3b and 3c for accuracy.
• Include all necessary information about the proprietor, partners, or executive officers as required in section 3d.
• Sign and date the form once completed to certify that the information provided is accurate.

• Attempt to issue the form yourself unless you are an authorized representative or licensed agent of the insurance carrier, as indicated at the bottom of the form.
• Use a PO Box for the address of the insured; always use the physical street address to ensure compliance.
• Leave any sections blank that are applicable to your situation. If a section does not apply, make sure to indicate that it's not applicable.
• Forget to send the Certificate of Insurance to the entity listed as the certificate holder in box 2, as this is a crucial step in the process.
• Ignore the notification requirements if the policy is canceled. Make sure to notify the certificate holder and the Workers' Compensation Board within the specified time frames.

The C-105.2 form, a Certificate of NYS Workers' Compensation Insurance Coverage, serves a crucial role, yet there are many misconceptions about its use and requirements. Understanding what the C-105.2 form entails and clearing up any confusion is essential for businesses operating in New York State.

• Only for Construction Projects: A common misconception is that the C-105.2 form is exclusive to construction projects. In reality, it's required for any New York State business that needs to prove workers' compensation insurance coverage, not just those in construction.

• Insurance Brokers Can Issue the Form: Another misunderstanding is that insurance brokers are authorized to issue the C-105.2 form. The truth is, only insurance carriers and their licensed agents have the authority to issue this certificate.

• No Expiration Concern: Some believe once the form is issued, it doesn't need to be renewed or monitored for expiration. However, this certificate is valid for one year after approval by the insurance carrier or until the policy expiration date, whichever comes first. Continuous compliance requires attention to these dates.

• Provides Coverage Extensions: There's also a belief that holding a C-105.2 form somehow extends or modifies the coverage outlined in the workers' compensation insurance policy. The certificate merely evidences existing coverage without amending or extending it.

• Automatic Policy Cancellation Notices: Many assume that if a policy is canceled, the insurance carrier is under no obligation to notify the certificate holder. However, carriers must notify both the certificate holder and the Workers' Compensation Board if the policy is canceled, whether due to nonpayment of premiums or for other reasons.

• One Form Fits All Locations: A common error is the assumption that one C-105.2 form suffices for businesses with multiple work locations. If coverage is specifically limited to certain locations in New York State (i.e., a Wrap-Up Policy), each relevant location must be accurately reflected.

• Grants Rights to Certificate Holder: Some people mistakenly believe that obtaining this certificate grants the certificate holder specific rights under the insured’s policy. This certificate is issued for informational purposes only and confers no rights upon the certificate holder.

• Substitute for Policy Documents: It's wrongly assumed that the C-105.2 can serve as a substitute for the actual insurance policy documents during legal or commercial assessments. This certificate cannot replace the detailed provisions and conditions of the actual insurance policy.

• Non-Compliance Has No Consequences: Many businesses underestimate the importance of this form, thinking non-compliance has minimal impact. In reality, failure to provide this certificate when required can result in significant legal and operational consequences, including restrictions on issuing permits or entering into contracts.

• Applicable Only to Large Businesses: A final misconception is that only large businesses need to concern themselves with the C-105.2. This certificate is mandatory for any business in New York State that employs workers, regardless of its size, making understanding and compliance essential for all.

Dispelling these misconceptions ensures that businesses can navigate the requirements of New York State's Workers' Compensation Law effectively, avoiding potential pitfalls that arise from misunderstanding the purpose and use of the C-105.2 form.

Understanding the C-105.2 form is crucial for businesses operating in New York State. This form serves as a certificate of Workers' Compensation Insurance Coverage, which is mandatory under state law. Here are key takeaways regarding the completion and usage of this form:

• The legal name and address of the insured business, along with contact information such as business telephone number and relevant identification numbers (such as the Unemployment Insurance Employer Registration Number and Federal Employer Identification Number), must be accurately filled out.
• It is necessary to specify the name and address of the entity requesting proof of Workers' Compensation Insurance Coverage.
• The insurance carrier details, including the name of the carrier and the policy number, alongside the policy's effective period, are critical components that must be provided.
• If the coverage is limited to certain locations within New York State, those locations must be explicitly stated on the form.
• This certificate does not amend or extend the coverage beyond what the policy states. It only serves as evidence of coverage for Workers' Compensation as long as the underlying policy is active.
• There are specific notification requirements for the insurance carrier or licensed agent regarding policy cancellation. They must inform both the certificate holder and the Workers' Compensation Board within the stipulated time frame depending on the reason for cancellation.

This form, therefore, plays a vital role in ensuring that businesses comply with New York State's Workers' Compensation Law requirements. It is not just a formality but a crucial document that affirms a business's adherence to state regulations, providing peace of mind to both employers and employees.