All private insurance carriers and their licensed insurance agents that issue NY workers’ compensation insurance policies are authorized to issue the form C-105.2 as their Certificate of NYS Workers’ Comp Insurance. The NYS State Insurance Fund (NYSIF) uses the U-26.3 form as its Certificate of NYS Workers’ Compensation Insurance.

Businesses covered by a NYS workers’ compensation insurance policy (NY listed under Item 3A on the Information Page of the insurance policy) and applying for a permit, license or contract from a government entity in NYS will request that their insurer provide a C-105.2 form to that government entity as proof that the business is covered by a New York State workers’ compensation insurance policy. (Only private insurance carriers licensed to write NYS workers compensation insurance policies and their licensed NYS agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it.)

Please note that the carrier or licensed agent can fill out the form with limited info from the insured. The insured should supply the carrier or licensed agent with the mailing address of the government entity, requiring the certificate, that will be notified in the event that the policy is canceled. (IE. Building Department, Town of Colonie, 347 Old Niskayuna Road, Latham, New York 12110)

How to Obtain Form C-105.2

If you are a private insurance carrier licensed to write NYS workers’ compensation insurance policies (NY listed under Item 3A on the Information Page of the insurance policy), 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 workers’ compensation insurance policy that is issuing the C-105.2 form.

If you are a licensed insurance AGENT that is authorized to write NYS workers’ compensation insurance policies (NY listed under Item 3A on the Information Page of the insurance policy), 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 workers’ compensation insurance policy.

If you are NOT a private insurance carrier or one of their licensed agents licensed to write NYS workers’ compensation insurance policies (NY listed under Item 3A on the Information Page of the insurance policy), then your client should check with their NYS workers’ compensation insurance carrier for this form.