Related links
Self-Insured Employers Workers Compensation Forms
Board-approved self-insurers must email the Boards Self-Insurance Office at selfinsurance@wcb.ny.gov to obtain this form. SI-105.2P (2/13), Certificate of
Learn more
state of new york workers compensation board
Jan 26, 2023 The County Self-Insurer must file this certificate with the Workers Compensation Boards Self-Insurance Office. (See reverse.) Under penalty of
Learn more
NYSDFS: Instructions on How to File Certification of Compliance
This certification can be made by the Board of Directors, a Senior Officer, or in the case of an individual licensed person, by self. Please indicate who is
Learn more