The Monroe County Department of Public Health is required to ensure that permit applicants are in compliance with New York State Workers' Compensation/Disability requirements at the time a permit is issued. ACORD forms are not acceptable documentation.
Links to examples of the various forms:
Examples of acceptable Workers' Compensation certificates:
- C-105.2 Certificate of NYS Workers' Compensation Insurance Coverage
- U-26.3 Certificate of Workers' Compensation Insurance
- SI-12 Self-Insurance Certification
- GSI-105.2 Certificate of Participation in Workers' Compensation Group Self-Insurance
Examples of acceptable Disability Coverage documentation:
- DB-120.1 Certificate of Insurance Coverage under the NYS Disability Benefits Law
- DB-155 Compliance with Disability Benefits Law (Self-Insurance)
Example of an exemption from Workers' Compensation, Disability, or both Workers' Compensation and Disability:
Entities eligible for an exemption can request a Certificate of Attestation of Exemption through the Workers' Compensation website
For details about this requirement, see the NY Workers' Compensation Board's publication:
If you have questions, please contact the relevant program.