The Workers’ Compensation Law requires that before a New York State or municipal agency, department, board, commission or office issues any permit or license, you must provide the completed forms as shown below to the Village of Scotia prior to permit issuance.

The ONLY ACCEPTABLE forms are as follows: (See below sheet “ NYS Workers’ Compensation Board page 5 dated December 1, 2008” )

Group Form No. Description
A CE-200 Certificate of Attestation For New York Entities With No Employees And Certain Out Of State Entities That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage Is Not Required.
B C-105.2 (9-07) Certificate of NYS Workers’ Compensation Insurance Coverage.
SI-12 (10-03) Certificate of Workers’ Compensation Self Insurance.
GSI-105.2 (2/02) Certificate of Participation in Workers’ Compensation Group Self Insurance.
U-26.3 New York State Insurance Fund Certificate of Workers’ Compensation Insurance.
C DB-120.1 Certificate of Disability Benefits Insurance
DB-155 (1-98) Certificate of Disability Benefits Self-Insurance.

Please note that for building permits ONLY, certain homeowners of 1, 2, 3 or 4 family owner-occupied residences serving as their own General Contractor may be eligible to file Form BP-1 (The homeowner obtains this form from either the Building Department or on the Board’s website, //www.wcb.ny.gov/, under the heading “Forms.” )

Questions regarding these forms should be addressed to the NYS Workers Compensation Board, Bureau of Compliance at (877) 632-4996.