Workers’ Compensation and Disability Insurance Requirements for Obtaining a Department of Health Permit

  • Workers’ Compensation and Disability Insurance Requirements for Obtaining a Department of Health Permit is also available in Portable Document Format (PDF)

    Before a Department of Health permit can be issued, you must prove compliance with NYS Workers’ Compensation AND Disability and Paid Family Leave Benefits Insurance requirements.

    If You Maintain Workers' Compensation and Disability Insurance Coverage

    The following forms must be submitted with each permit application:

    1.  Workers' Compensation (Submit one from this list): 2. Disability Insurance (Submit one from this list):
    1. Form C-105.2 (issued by your insurance carrier)
    2. Form U-26.3 (issued by the State Insurance Fund)
    3. Form SI-12
    4. Form GSI-105.2
    1. Form DB-120.1 (issued by your insurance carrier)
    2. Form DB-155

    Where do I get these forms?

    Contact your insurance carrier for these forms.

    Do I have to submit new forms each time I apply?

    Yes, please submit NEW forms with each permit application. We are unable to substitute insurance forms submitted with recent permit applications.

    The legal entity named on the insurance forms must match the Legal Operator listed on the permit application.

    If You Do Not Maintain Workers' Compensation and/or Disability Insurance Coverage

    If you do not maintain this coverage and are exempt from Workers' Compensation and/or Disability coverage, you need to provide a CE-200 Attestation of Exemption Certificate.

    You can also request an Exemption Certificate by calling the NYS Workers’ Compensation Board at 866-298-7830. Please note, it can take up to 8 weeks to process this request.

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