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Blank Ce200 Form

The CE-200 form is the Application for Certificate of Attestation of Exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. This form is designed for entities with no employees or out-of-state businesses that perform all work outside New York State. It allows applicants to certify to government entities that they are not required to carry workers' compensation or disability benefits insurance.

Outline

The CE200 form is an essential document for individuals and entities seeking exemption from New York State's Workers' Compensation and Disability Benefits insurance coverage. This application is specifically designed for those with no employees or out-of-state businesses performing all work outside New York State. It allows applicants to demonstrate to government entities that they are not required to maintain these insurances when applying for permits, licenses, or contracts. The CE200 form must be filled out completely and submitted to the Workers' Compensation Board via fax or mail. Once processed, which may take up to four weeks, a certificate of attestation of exemption will be mailed to the applicant. For immediate needs, an online application is available, allowing users to print the certificate upon completion. The form requires personal and legal entity information, including the applicant's title and nature of business, and it includes sections to clarify the reasons for exemption. It is crucial to review the accompanying instructions carefully before submission to ensure accuracy and compliance with New York State laws.

Sample - Ce200 Form

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New York State Workers' Compensation Board

Application for Certificate of Attestation of Exemption

from

New York State Workers’ Compensation and/or

Disability and Paid Family Leave Benefits Insurance Coverage.

For NYS workers’ compensation exemption, this application may only be completed by entities with no employees or

out-of-state entities obtaining contracts for which ALL work is performed outside of NYS. For NYS disability and paid

family leave benefits exemption, it may only be completed by entities without employees or those with employees, as

defined by the NYS Disability and Paid Family Leave Benefits Law, working in NYS for less than thirty days in a

calendar year.

A certificate of attestation of exemption can ONLY be used to attest to a government entity that the applicant requesting a

permit, license or contract from that government entity is not required to carry workers’ compensation and/or disability

and paid family leave benefits insurance.

The application must be completed in its entirety and submitted to the Workers’ Compensation Board by fax or mail. The

application will be processed in the order received and a certificate of attestation of exemption will be mailed to the

applicant. This process may take up to four weeks.

To obtain a certificate immediately, please use the on-line application at

www.businessexpress.ny.gov

. Once the

application is completed on-line, you can immediately print the certificate on your printer.

Please review the separate instructions (form CE-200 instructions) prior to completing this application. Please print

clearly.

1. Applicant Personal Information:

First Name: ____________________________ Last Name: ______________________________________

Street Address: ____________________________________________________________________________

City: ___________________________________ State: ____________________ Zip: __________________

Country (If other than U.S.) __________________________________________________________________

Personal Phone Number ( ______ ) ___________________________

2. Your Title (check only one)

 Sole Proprietor  Treasurer

 President  Partner

 Vice President  Member

 Secretary  Trustee

 Homeowner  Board Member

 Other (please provide title) __________________________________________________________

3. Legal Entity Information:

Business Federal ID (If none, enter social security number): _________________________________________

Legal Entity Name: _________________________________________________________________________

Doing Business As Name_____________________________________________________________________

Business Phone: ( _______ )__________________E-mail __________________________________________

 Check here if business address is the same as the applicant’s personal address. If different, enter business

address below.

Business Street Address: _____________________________________________________________________

City: _________________________________ State: _____________________ Zip:_____________________

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Country (If other than U.S.) __________________________________________________________________

4. Permit/License/Contract Information:

A. Nature of Business:(please check only one)

 Construction/Carpentry  Electrical

 Demolition  Landscaping

 Plumbing  Farm

 Restaurant / Food Service  Trucking / Hauling

 Food CartVendor  Horse Trainer/Owner

 Homeowner  Hotel / Motel

 Bar / Tavern  Mobile - Home Park

 Other (please explain)

______________________________________________________________

B. Applying for:

 License (list type) __________________________________________________________________

 Permit (list type) ___________________________________________________________________

 Contract with Government Agency

Issuing Government Agency: _____________________________________________________________

(e.g. New York City Building Department, Ulster County Health Department, New York State

Department of Labor, etc.)

5. Job Site Location Information: (Required if applying for a building, plumbing, and electrical permit)

A. Job Site Address

Street address________________________________________________________________________

City: _________________________ State: ___________ Zip: ________County: ________________

B. Dates of project: (mm/dd/yyyy) ___________________ to:(mm/dd/yyyy) _________________________

Estimated Dollar amount of project:

 $0 - $10,000  $50,001 - $100,000

 10,001- $25,000  Over $100,000

 $25,001 - $50,000

6. Partners/Members/Corporate Officers -must list all with titles except for limited partnerships which

must include only general partners. Sole proprietors can skip this section.

Name: ________________________________________ Title: _____________________________________

(Attach additional sheet if necessary)

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Employees of the Workers’ Compensation Board cannot assist applicants in answering questions in the

following two sections. Please contact an attorney if you have any questions regarding these sections.

7. Please select the reason that the legal entity is NOT required to obtain New York State

Specific Workers’ Compensation Insurance Coverage:

□ A. The applicant is NOT applying for a workers' compensation certificate of attestation of exemption and will show

a separate certificate of NYS workers' compensation insurance coverage.

□ B. The business is owned by one individual and is not a corporation. Other than the owner, there are no employees,

day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family

members) or subcontractors.

□ C. The business is a LLC, LLP, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a

corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed

employees, part-time employees, unpaid volunteers (including family members) or subcontractors.

□ D. The business is a one person owned corporation, with that individual owning all of the stock and holding all

offices of the corporation. Other than the corporate owner, there are no employees, day labor, leased employees,

borrowed employees, part-time employees, other stockholders, unpaid volunteers (including family members) or

subcontractors.

□ E. The business is a two person owned corporation, with those individuals owning all of the stock and holding all

offices of the corporation (each individual must hold an office and own at least one share of stock). Other than the

two corporate officers/owners, there are no employees, day labor, leased employees, borrowed employees, part-time

employees, other stockholders, unpaid volunteers (including family members) or subcontractors.

□ F. The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for

clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code)

with no

compensated individuals providing services except for clergy providing ministerial services; and persons performing

teaching or nonmanual labor. [Manual labor includes but is not limited to such tasks as filing; carrying materials

such as pamphlets, binders, or books; cleaning such as dusting or vacuuming; playing musical instruments; moving

furniture; shoveling snow; mowing lawns; and construction of any sort.]

□ G. The business is a farm with less than $1,200 in payroll the preceding calendar year.

□ H. The applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence.

The homeowner ONLY has uncompensated friends and family working on his/her residence or is hiring individuals

a total of less than 40 aggregate hours per week and has a current homeowner’s insurance policy that covers the

property.

□ I. Other than the business owner(s) and individuals obtained from a temporary service agency, there are no

employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including

family members) or subcontractors. Other than the business owner(s), all individuals providing services to the

business are obtained from a temporary service agency and that agency has covered these individuals for New York

State workers' compensation insurance. In addition, the business is owned by one individual or is a partnership

under the laws of New York State and is not a corporation; or is a one or two person owned corporation, with those

individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation,

each individual must be an officer and own at least one share of stock). A Temporary Service Agency is a business

that is classified as a temporary service agency under the business’s North American Industrial Classification

System (NAICS) code.

Temporary Service Agency

Name _________________________________________________ Phone #_______________________________

□ J. The out-of-state entity has no NYS employees and/or NYS subcontractors AND ALL work related to the permit,

license or contract is done outside of NYS; OR ALL employees are direct employees of a government entity outside

of New York. Please provide coverage information.

Carrier______________________________________Policy #__________________________________________

Policy start date _____________________________Policy expiration date ________________________________

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8. Please select the reason that the legal entity is NOT required to obtain New York State

Statutory Disability and/or Paid Family Benefits Insurance Coverage:

□

The applicant is NOT applying for a disability and paid family benefits exemption and will show a separate

certificate of NYS statutory disability benefits insurance coverage.

□

The business MUST be either: 1) owned by one individual; OR 2) is a partnership (including

LLC, LLP, PLLP, RLLP, or LP) under the laws of New York State and is not a corporation; OR

3) is a one or two person owned corporation, with those individuals owning all of the stock and holding

all offices of the corporation (in a two person owned corporation each individual must be an officer and

own at least one share of stock); OR 4) is a business with no NYS location. In addition, the business

does not require disability and paid family leave benefits coverage at this time since it has not employed

one or more individuals on at least 30 days in any calendar year in New York State. (Independent

contractors are not considered to be employees under the Disability and Paid Family Leave Benefits

Law.)

□

The applicant is a political subdivision that is legally exempt from providing statutory disability and/or paid

family leave benefits coverage.

□

The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for

clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code)

with no

compensated individuals providing services except for executive officers, clergy, sextons, teachers or professionals.

□ E.

The business is a farm and all employees are farm laborers.

□

The applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence.

The homeowner has not employed one or more individuals on at least 30 days in any calendar year in New York

State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave

Benefits Law.)

□ G.

Other than the business owner(s) and individuals obtained from the temporary service agency, there are no other

employees. Other than the business owner(s), all individuals providing services to the business are obtained from a

temporary service agency and that agency has covered these individuals for New York State disability and paid

family leave benefits insurance. In addition, the business is owned by one individual or is a partnership under the

laws of New York State and is not a corporation; or is a one or two person owned corporation, with those

individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation,

each individual must be an officer and own at least one share of stock). A Temporary Service Agency is a business

that is classified as a temporary service agency under the business’s North American Industrial Classification

System (NAICS) code.

I affirm that due to my position with the above-named business I have the knowledge,

information and legal authority to make this Application for Certificate of Attestation of

Exemption. I hereby affirm that the information provided above is true and that I have not

submitted any materially false statements and I make this application for a Certificate of

Attestation of Exemption under the penalties of perjury. I further affirm that I understand

that any false statement, representation, or concealment will subject me to felony

prosecution, including jail and civil liability in accordance with the Workers’

Compensation Law and all other New York State Laws.

Signature Title Date

Click for PDF

Form Information

Fact Name	Description
Purpose	The CE-200 form is used to apply for a Certificate of Attestation of Exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage.
Eligibility	This application can only be completed by entities with no employees or out-of-state entities whose work is entirely performed outside of New York State.
Submission Process	The completed application must be sent to the Workers’ Compensation Board via fax or mail, and processing may take up to four weeks.
Governing Laws	This form is governed by the New York State Workers' Compensation Law and the New York State Disability Benefits Law.

Detailed Guide for Filling Out Ce200

Completing the CE-200 form is a crucial step for those seeking an exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. After filling out the form, it must be submitted to the Workers’ Compensation Board via fax or mail. Expect the processing time to take up to four weeks, although an online option is available for immediate certification.

Applicant Personal Information: Fill in your first name, last name, street address, city, state, zip code, and country (if applicable). Include your personal phone number.
Your Title: Select your title from the provided options, such as Sole Proprietor or President. Only check one box.
Legal Entity Information: Enter your Business Federal ID or social security number if you do not have a Federal ID. Provide the legal entity name and any "Doing Business As" name. Include your business phone number and email address. If your business address is the same as your personal address, check the corresponding box. If different, enter the business address details.
Permit/License/Contract Information: Indicate the nature of your business by checking the appropriate box. Specify what type of permit, license, or contract you are applying for and the issuing government agency.
Job Site Location Information: If you are applying for a building, plumbing, or electrical permit, fill in the job site address, including city, state, zip, and county. Provide the project dates and estimated dollar amount of the project.
Partners/Members/Corporate Officers: List all partners, members, or corporate officers with their titles, except for limited partnerships which only require general partners. Sole proprietors can skip this section.
Reason for Exemption: Select the appropriate reason for not needing New York State Workers’ Compensation Insurance Coverage by checking the relevant box.
Disability Benefits Insurance Coverage: Similarly, select the appropriate reason for not needing New York State Disability Benefits Insurance Coverage by checking the relevant box.
Affirmation: Sign and date the application, affirming that the information provided is accurate and acknowledging the penalties for false statements.

Obtain Answers on Ce200

What is the CE-200 form?
The CE-200 form is the New York State Workers' Compensation Board Application for Certificate of Attestation of Exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. It is primarily used by entities that do not have employees or by out-of-state entities that perform all work outside of New York State.
Who can complete the CE-200 form?
This application can only be completed by:
- Entities with no employees.
- Out-of-state entities obtaining contracts for which all work is performed outside of New York State.
- Entities with employees working in New York State for less than thirty days in a calendar year.
What is the purpose of the CE-200 form?
The CE-200 form is used to attest to a government entity that the applicant is not required to carry workers’ compensation and/or disability benefits insurance. This certificate is essential for obtaining permits, licenses, or contracts from government entities.
How do I submit the CE-200 form?
The completed form must be submitted to the Workers’ Compensation Board by either fax or mail. It is important to ensure that the application is filled out completely to avoid delays in processing.
How long does it take to process the CE-200 form?
Processing the application can take up to four weeks. However, for those needing the certificate immediately, an online application is available at www.wcb.state.ny.us. After completing the online application, you can print the certificate right away.
What information is required to complete the CE-200 form?
The application requires various details, including:
- Applicant's personal information (name, address, phone number).
- Title of the applicant (e.g., Sole Proprietor, President).
- Legal entity information (Federal ID or Social Security number, business name).
- Details about the permit, license, or contract being applied for.
- Job site location information, if applicable.
What happens if I provide false information on the CE-200 form?
Providing false information on the application can lead to serious consequences, including felony prosecution and civil liability under New York State laws. It is crucial to ensure that all information is accurate and truthful before submission.

Common mistakes

Filling out the CE200 form can be straightforward, but many people make common mistakes that can lead to delays or rejections. One frequent error is leaving out essential personal information. Applicants often forget to include their full name, address, or phone number. This information is crucial for the Workers' Compensation Board to process the application efficiently. Always double-check that all fields are filled in completely.

Another mistake is failing to provide accurate legal entity information. Some applicants mistakenly enter a business name or ID that does not match the official records. This can create confusion and may result in the application being rejected. Ensure that the business name and Federal ID number are correct and consistent with what is on file with the state.

Many applicants also overlook the title section. Choosing the wrong title can lead to misunderstandings about the applicant's authority to submit the application. It’s important to select the title that accurately reflects your role within the organization. If you are unsure, consult your business documents to find the correct title.

In addition, some people neglect to check the appropriate boxes regarding their exemption status. This section is critical because it determines whether the applicant qualifies for the exemption. Failing to select the correct options can lead to unnecessary delays or a denial of the application. Take your time to read through the choices carefully.

Another common error is not signing the application. The signature is a vital part of the process, as it confirms that the information provided is true and that the applicant has the authority to submit the application. Without a signature, the application cannot be processed. Always remember to sign and date the form before submission.

Lastly, applicants often forget to review the instructions before filling out the form. Skipping this step can lead to mistakes that could have been easily avoided. The instructions provide essential guidance on how to complete the form correctly. Take a moment to read through them thoroughly before starting the application.

Documents used along the form

The CE-200 form is a vital document for those seeking exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance coverage. However, it is often accompanied by other forms and documents that help clarify the applicant's status and intentions. Below is a list of related forms that may be necessary or helpful in conjunction with the CE-200.

CE-200 Instructions: This document provides detailed guidance on how to properly complete the CE-200 form, ensuring that applicants understand all requirements and avoid common mistakes.
WC-1 Form: This form is used to report workplace injuries and illnesses. It is essential for businesses that have employees and need to maintain compliance with workers' compensation regulations.
DB-120 Form: This is the application for New York State Disability Benefits Insurance. Businesses with employees must submit this form to secure disability benefits coverage.
DB-300 Form: This form serves as a notice of compliance with the New York State Disability Benefits Law. It is crucial for employers to keep this on file to demonstrate their compliance.
WC-2 Form: This is a wage statement used to report an employee's wages and other compensation to the Workers' Compensation Board. It helps in determining benefit amounts in case of a claim.
Form 1099-MISC: Independent contractors may receive this form, which reports payments made to them. It is important for businesses that hire freelancers or contractors.
Certificate of Insurance: This document proves that a business has the required insurance coverage. It is often requested by government entities when applying for permits or licenses.
Business License Application: Depending on the type of business, this application is necessary to obtain the appropriate licenses from local or state authorities.
Partnership Agreement: If the business is a partnership, this document outlines the terms and conditions agreed upon by the partners, including profit-sharing and responsibilities.
LLC Operating Agreement: For Limited Liability Companies, this agreement details the management structure and operating procedures, which can be crucial for legal clarity.

Understanding these forms and their purposes can significantly streamline the process of obtaining the necessary exemptions and compliance for your business. Each document plays a role in ensuring that you meet legal requirements and protect your interests as you navigate the regulatory landscape.

Similar forms

The CE-200 form is a specific application used in New York State for entities seeking an exemption from workers' compensation and/or disability benefits insurance coverage. It is similar to several other documents in that they all serve specific purposes related to business operations and compliance with state regulations. Below are five documents that share similarities with the CE-200 form, along with explanations of how they relate:

DB-120 Form: This form is a request for a certificate of disability benefits insurance coverage. Like the CE-200, it is used by businesses to demonstrate compliance with New York State laws regarding disability benefits. Both forms require detailed information about the business and its employees.
WC-1 Form: This is the New York State Workers' Compensation Insurance Coverage form. It is similar to the CE-200 in that it certifies a business's compliance with workers' compensation insurance requirements. Both forms require the applicant to provide personal and business information, as well as details about the nature of their work.
NYC Department of Consumer Affairs License Application: This application is necessary for businesses seeking various licenses in New York City. Like the CE-200, it requires applicants to provide extensive information about their business operations and ownership structure. Both documents serve as a means to verify compliance with local regulations.
Form 1099-MISC: While this form is used for reporting income paid to independent contractors, it shares a commonality with the CE-200 in that it is crucial for businesses to maintain accurate records of their workforce. Both documents help define the relationship between the business and its workers, impacting insurance and tax obligations.
LLC Formation Documents: These documents are required to legally establish a Limited Liability Company in New York. Similar to the CE-200, they require detailed information about the business structure and ownership. Both sets of documents are essential for compliance with state laws and regulations governing business operations.

Dos and Don'ts

When filling out the CE-200 form, it is important to follow certain guidelines to ensure accuracy and compliance. Below are four things you should and shouldn't do:

Do: Complete the application in its entirety. Each section must be filled out to avoid delays.
Do: Print clearly. Legible handwriting helps prevent misunderstandings and errors in processing.
Don't: Submit the application without the required signatures. The applicant must sign the form before submission.
Don't: Use an accountant or lawyer to file on your behalf. The applicant must have the legal authority to submit the application.

Misconceptions

Understanding the CE-200 form is crucial for those seeking exemptions from New York State Workers’ Compensation and Disability Benefits Insurance. However, several misconceptions persist regarding its use and requirements. Below is a list of nine common misconceptions, each clarified for better understanding.

Only businesses with employees can apply for the CE-200 form. This is incorrect. The form can be completed by entities with no employees or out-of-state entities where all work is performed outside New York State.
The CE-200 form guarantees immediate exemption from insurance requirements. This is misleading. While it can expedite the process, the application still needs to be processed, which may take up to four weeks unless submitted online.
All businesses can use the CE-200 form regardless of their structure. This is not true. Only specific types of businesses, such as sole proprietorships or certain partnerships, are eligible to apply without needing workers' compensation coverage.
Once a CE-200 certificate is obtained, it can be used for any purpose. This is a misconception. The certificate can only be used to attest to a government entity regarding insurance requirements for permits, licenses, or contracts.
Filing the CE-200 form is a simple process that requires minimal information. This is misleading. The application must be completed in its entirety, requiring detailed information about the applicant and the business.
Independent contractors are considered employees under the CE-200 form. This is incorrect. Independent contractors do not count as employees when determining eligibility for the exemption.
Anyone can fill out the CE-200 form on behalf of the applicant. This is not accurate. The applicant must have the legal authority to file the application, meaning they must sign it themselves.
The CE-200 form is only for construction-related businesses. This is a misconception. Various types of businesses, including farms and nonprofits, can apply for the exemption.
Once submitted, the application cannot be amended or updated. This is misleading. If there are errors or changes needed after submission, it is possible to contact the Workers' Compensation Board for guidance on how to proceed.

By dispelling these misconceptions, individuals and businesses can better navigate the application process and ensure compliance with New York State laws regarding workers' compensation and disability benefits.

Key takeaways

Filling out the CE-200 form is a crucial step for those seeking an exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. Here are key takeaways to keep in mind:

Eligibility Criteria: Only entities with no employees or out-of-state entities performing all work outside New York State can complete the application for workers’ compensation exemption.
Disability Benefits Exemption: This can be completed by entities without employees or those with employees working in New York for less than thirty days in a calendar year.
Use of Certificate: The certificate can only be used to demonstrate to a government entity that the applicant is not required to carry the specified insurance.
Application Submission: Complete the application in full and submit it to the Workers’ Compensation Board via fax or mail. Ensure all sections are filled out clearly.
Processing Time: Expect processing to take up to four weeks. For immediate needs, consider using the online application available on the Board’s website.
Personal Information: Provide accurate personal information including your name, address, and phone number. The applicant must have the legal authority to file the application.
Signature Requirement: The applicant must sign the application, affirming that all information is true and complete, and understand the penalties for false statements.

By following these guidelines, you can navigate the CE-200 form process with greater confidence and clarity.