Overview
Businesses covered by a statutory NYS disability and Paid Family Leave benefits insurance policy and applying for a permit, license or contract from a government entity in NYS will request that their insurer provide a Certificate of Insurance Coverage Disability and Paid Family Leave Benefits (Form DB-120.1) to that government entity as proof that the business is covered by a New York State disability and Paid Family Leave benefits insurance policy. Only insurance carriers licensed to write NYS disability and Paid Family Leave benefits insurance policies and their licensed NYS agents are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue it.
Self-Insured employers will provide Compliance With Disability Benefits Law (Form DB-155) in lieu of Form DB-120.1. Only the Office of Self-Insurance is authorized to issue Form DB-155.
How to obtain Form DB-120.1
If you are an insurance carrier licensed to write statutory NYS disability and Paid Family Leave benefits insurance policies, please send an email to Certificates@wcb.ny.gov and indicate who you are, your position within the insurance carrier, and the specific insurance carrier that has the NYS disability and Paid Family Leave benefits insurance policy and is issuing Form DB-120.1.
If you are a licensed insurance AGENT that is authorized to write NYS disability and Paid Family Leave benefits insurance policies please send an email to Certificates@wcb.ny.gov and indicate who you are, your AGENT license number (including the letters in front of your license number), and the specific insurance carrier that issued the NYS disability and Paid Family Leave benefits insurance policy.
If you are not an insurance carrier or one of their licensed agents with binding authority to underwrite statutory NYS disability and Paid Family Leave benefits insurance policies, then your client should check with their NYS disability benefits insurance carrier for this form.
How to obtain Compliance with disability benefits law (Form DB-155)
If you are self-insured, please send an email to SelfInsurance@wcb.ny.gov and indicate who you are, the name of the self-insured entity, and that you are seeking Form DB-155. More information can be found under the Self-Insured Employers section of the website.