Ce200 PDF Template

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. This form is designed for entities without employees or out-of-state entities performing work outside of New York State. Completing the CE-200 form is essential for those seeking an exemption to demonstrate to government entities that they are not required to carry specific insurance coverage.

To begin the process of filling out the CE-200 form, click the button below.

Article Guide

The CE200 form is a vital document for businesses and individuals seeking an exemption from New York State Workers' Compensation and Disability Benefits Insurance coverage. This application is specifically designed for entities that either have no employees or are out-of-state businesses performing all work outside of New York. It serves as a formal request for a Certificate of Attestation of Exemption, which can only be utilized to inform government entities that the applicant is not required to maintain these insurance coverages. To qualify for this exemption, applicants must meet certain criteria outlined in the form, such as having no employees or only working in New York for a limited number of days in a year. Completing the CE200 form requires providing personal and legal entity information, including the nature of the business and the specific permit, license, or contract being applied for. Once the application is submitted, it will be processed in the order received, and a certificate will be mailed to the applicant, which may take up to four weeks. For those needing immediate access, an online application is available, allowing for instant printing of the certificate. It is crucial to follow the detailed instructions provided with the form to ensure accurate completion and submission.

Ce200 Preview

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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

↓ Ce200

File Properties

Fact Name	Details
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 for Workers' Compensation Exemption	This exemption can only be claimed by entities with no employees or out-of-state entities whose work is performed entirely outside of New York State.
Eligibility for Disability Benefits Exemption	Entities without employees, or those with employees working in New York for less than thirty days in a calendar year, may apply for this exemption.
Usage of Certificate	The certificate can only be used to attest to a government entity that the applicant is not required to carry the mentioned insurances.
Application Submission	The completed application must be submitted to the Workers' Compensation Board via fax or mail.
Processing Time	Processing of the application may take up to four weeks, but an online application can yield an immediate certificate.
Legal Authority	The applicant must have the knowledge and legal authority to submit the application. An attorney or accountant cannot file on behalf of the applicant.
Governing Law	The CE-200 form is governed by the New York State Workers' Compensation Law and the New York State Disability Benefits Law.

Instructions on Utilizing Ce200

Filling out the CE-200 form is a straightforward process, but it requires careful attention to detail. This application is essential for obtaining a certificate that confirms an exemption from New York State Workers' Compensation and/or Disability Benefits Insurance Coverage. After completing the form, you will need to submit it to the Workers' Compensation Board either by fax or mail. The processing time can take up to four weeks, so it is advisable to plan accordingly.

Applicant Personal Information: Fill in your first name, last name, street address, city, state, zip code, and country (if not the U.S.). Provide a personal phone number.
Your Title: Check the box next to your title, such as Sole Proprietor, Treasurer, or President. Only select one title.
Legal Entity Information: Enter your Business Federal ID or Social Security number if there is no 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 box. If different, enter the business address details.
Permit/License/Contract Information: Indicate the nature of your business by checking one option. Specify what you are applying for, whether it is a license, permit, or contract, and name the issuing government agency.
Job Site Location Information: If applicable, provide the job site address, including city, state, zip code, and county. Enter the project dates and the estimated dollar amount of the project.
Partners/Members/Corporate Officers: List all partners or corporate officers, including their titles. Sole proprietors can skip this section. Attach an additional sheet if necessary.
Workers' Compensation Insurance Coverage Reason: Select the reason why your legal entity is not required to obtain workers' compensation insurance coverage. Review the options carefully and check the appropriate box.
Disability Benefits Insurance Coverage Reason: Select the reason why your legal entity is not required to obtain disability benefits insurance coverage. Again, review the options and check the appropriate box.
Affirmation: Sign the application, providing your title and the date. Ensure you affirm that the information is true and that you understand the implications of providing false information.

Important Facts about Ce200

What is the CE-200 form?

The CE-200 form is an application used in New York State to obtain a Certificate of Attestation of Exemption from Workers' Compensation and/or Disability Benefits Insurance Coverage. This form is specifically designed for entities that do not have employees or for out-of-state entities whose work is performed entirely outside New York State. It serves as proof to government entities that the applicant is not required to carry these types of insurance.

Who can complete the CE-200 form?

The CE-200 form can only be completed by specific entities. These include businesses with no employees, out-of-state entities working entirely outside New York State, or those with employees working in New York for less than thirty days in a calendar year. Additionally, sole proprietors, partnerships, and certain non-profit organizations may also qualify to submit this application, provided they meet the specific criteria outlined in the form.

How do I submit the CE-200 form?

To submit the CE-200 form, applicants must complete it in its entirety and send it to the Workers' Compensation Board via fax or mail. The application will be processed in the order it is received, and a certificate will be mailed back to the applicant. This process can take up to four weeks. For immediate needs, applicants can use the online application available at the New York Workers' Compensation Board's website, where they can complete the form and print the certificate right away.

What information is required on the CE-200 form?

Applicants must provide personal information, including their name, address, and contact details. They also need to indicate their title within the business. Additionally, the form requires legal entity information, such as the business's Federal ID number or social security number, and the nature of the business. Applicants must specify the type of permit, license, or contract they are applying for and provide details about the job site if applicable.

What happens if I provide false information on the CE-200 form?

Providing false information on the CE-200 form can have serious consequences. The applicant affirms that the information is true and acknowledges that any false statements can lead to felony prosecution, including potential jail time and civil liability under New York State laws. It is crucial to ensure that all information submitted is accurate and complete to avoid these severe repercussions.

Common mistakes

Filling out the CE-200 form can be a straightforward process, but many applicants make mistakes that can delay their exemption requests. One common mistake is failing to provide complete personal information. The form requires specific details such as your first and last name, address, and phone number. Omitting any of these can lead to processing delays. Always double-check that every field is filled out clearly and accurately.

Another frequent error occurs in the section regarding the legal entity information. Applicants often confuse the legal entity name with the "doing business as" name. It's crucial to ensure that the legal entity name matches exactly with what is registered with the Department of State. This discrepancy can result in the application being returned or rejected, causing unnecessary frustration.

Many individuals also overlook the requirement to select the appropriate reason for exemption. The CE-200 form includes several options, and selecting the wrong one can lead to significant complications. Carefully read through the options and choose the one that accurately reflects your situation. Misclassification can delay the approval process or even result in a denial of the exemption.

Moreover, applicants sometimes forget to sign the form before submission. The signature is not just a formality; it confirms that the information provided is true and that you have the authority to submit the application. Without a signature, the application will be deemed incomplete and will not be processed.

Lastly, many people fail to review the instructions thoroughly before filling out the form. The CE-200 form comes with specific guidelines that are crucial for successful completion. Taking a few moments to read through these instructions can save you time and prevent mistakes. By being mindful of these common pitfalls, you can ensure a smoother application process and increase your chances of receiving your exemption certificate promptly.

Documents used along the form

The CE200 form is an essential document for entities seeking an exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage. When applying for this exemption, several other forms and documents may also be required to ensure compliance with state regulations. Below is a list of commonly associated documents that may accompany the CE200 form.

CE-200 Instructions: This document provides detailed guidance on how to complete the CE200 form accurately. It outlines the necessary information required and any specific instructions related to the application process.
Workers’ Compensation Insurance Certificate: This certificate serves as proof that a business has obtained workers' compensation insurance coverage. If an applicant has this certificate, they may not need to apply for an exemption.
Disability Benefits Insurance Certificate: Similar to the workers' compensation certificate, this document verifies that a business is covered under New York State's disability benefits insurance. It is essential for businesses that employ individuals in New York State.
Business License: A valid business license may be required to demonstrate that the entity is legally permitted to operate within its specific industry. This license varies by type of business and locality.
Federal Employer Identification Number (EIN): This number is assigned by the IRS and is necessary for tax purposes. It is often required on the CE200 form to identify the business entity.
Proof of Business Structure: Documentation that outlines the legal structure of the business (e.g., LLC, corporation, sole proprietorship) may be needed to clarify the entity's status and eligibility for exemption.

It is important to gather all necessary documents before submitting the CE200 form to avoid delays in processing. Ensuring compliance with New York State regulations is crucial for a smooth application process. If there are any uncertainties regarding the requirements, consulting with a legal professional is advisable.

Similar forms

The CE200 form serves as an application for a certificate of attestation of exemption from New York State Workers' Compensation and/or Disability Benefits Insurance Coverage. Several other documents share similarities with the CE200 form in terms of purpose and function. Below is a list of these documents:

WC-1 Form: This form is used to report an employee's injury or illness to the Workers' Compensation Board. Like the CE200, it is essential for compliance with state regulations regarding workers' compensation.
DB-120 Form: This is a notice of compliance for disability benefits insurance. It serves a similar purpose as the CE200 in confirming that a business is exempt from carrying disability benefits insurance.
CE-300 Form: This form is used to request a waiver from the requirement to carry workers' compensation insurance. It parallels the CE200 in that both forms facilitate exemptions based on specific criteria.
Form 1099-MISC: This document is used for reporting payments made to independent contractors. It is relevant to the CE200 as both address employment status and insurance requirements.
Form W-9: This form requests taxpayer identification information from contractors. Like the CE200, it is necessary for businesses to ensure compliance with tax regulations when hiring individuals.
LLC Formation Documents: These documents establish a limited liability company. They are similar to the CE200 as they outline the structure and ownership of a business, impacting insurance requirements.
Certificate of Good Standing: This certificate confirms that a business is compliant with state regulations. It is akin to the CE200 in that both documents verify a business's legal standing and compliance with state laws.

Dos and Don'ts

When filling out the CE-200 form for a Certificate of Attestation of Exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage, it is essential to follow specific guidelines. Here are nine important do's and don'ts to keep in mind:

Do read the instructions carefully before starting the application.
Do ensure that all required fields are completed clearly and accurately.
Do provide your legal entity name as it is registered with the Department of State.
Do include a valid phone number and email address for communication purposes.
Do submit the application via mail or fax, as specified in the instructions.
Don't attempt to have someone else, such as an accountant or lawyer, submit the application on your behalf.
Don't leave any sections blank; incomplete applications may delay processing.
Don't use a trade name for the legal entity name; it must match official records.
Don't forget to sign the application, as your signature is required for validation.

Following these guidelines will help ensure a smoother application process. Remember, the application will be processed in the order it is received, and it may take up to four weeks to receive your certificate. If you need immediate assistance, consider using the online application option available on the Workers’ Compensation Board's website.

Misconceptions

Understanding the CE-200 form can be challenging, and several misconceptions can lead to confusion. Here are six common misunderstandings:

Misconception 1: The CE-200 form is for all businesses regardless of their employee status.

This is incorrect. Only entities with no employees or specific out-of-state entities can complete this form for exemption from New York State Workers’ Compensation and/or Disability Benefits Insurance.

Misconception 2: The application can be submitted online for immediate processing.

While there is an online application available for immediate printing of the certificate, the traditional application submitted by fax or mail can take up to four weeks to process.

Misconception 3: Any business can claim an exemption from workers' compensation insurance.

Exemptions are only available to specific types of entities, such as sole proprietors without employees or certain partnerships, as defined by New York State law.

Misconception 4: The CE-200 form is only relevant for construction businesses.

This form applies to a variety of businesses, not just construction. It is relevant for any entity seeking a permit, license, or contract from a government agency.

Misconception 5: The CE-200 form can be filled out by anyone on behalf of the business.

Only the applicant, who has the legal authority and knowledge about the business, can complete and sign the application. An accountant or lawyer cannot file it for a client.

Misconception 6: Once submitted, the application cannot be amended or corrected.

While it is best to ensure accuracy before submission, if errors are found, applicants should contact the Workers’ Compensation Board for guidance on how to proceed.

Key takeaways

When filling out and using the CE200 form for New York State Workers' Compensation and/or Disability Benefits Insurance Coverage exemption, consider the following key takeaways:

Eligibility Criteria: Only entities without employees or out-of-state entities performing all work outside of New York State can apply for a workers' compensation exemption. For disability benefits, entities without employees or those with employees working in New York for less than thirty days may apply.
Purpose of the Certificate: The certificate of attestation of exemption is solely used to inform government entities that the applicant is not required to carry workers' compensation and/or disability benefits insurance.
Application Submission: Complete the application in its entirety and submit it to the Workers’ Compensation Board via fax or mail. Processing may take up to four weeks, but an online application can expedite this process.
Required Information: Ensure to provide accurate personal and legal entity information, including the business's Federal ID or Social Security number, and specify the nature of the business and the type of permit, license, or contract being applied for.
Signature Requirement: The applicant must sign the application, affirming the accuracy of the information provided. Misrepresentation may lead to serious legal consequences, including prosecution.