Db 820 2026

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The document is a supplement to the Certificate of Insurance for the New York Workers' Compensation Board, detailing the Disability and Paid Family Leave Benefits Law. It outlines the requirements for benefits payable to eligible employees, including benefit amounts, maximum duration, waiting periods, eligibility requirements, and employee contributions. The document emphasizes that benefits must meet or exceed specific legal standards and provides space for additional information regarding any differences in benefits.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the WCB Plan # and Employer FEIN at the top of the form. This information is crucial for identifying your insurance coverage.
In the section labeled 'Name of Employer', input the full name of your organization, followed by the 'Name of Carrier' which refers to your insurance provider.
Next, fill out the 'CLASS OR CLASSES OF EMPLOYEES' field, specifying which employee categories are covered under this plan.
For each class, provide details on 'BENEFIT AMOUNT MAXIMUM OR RATE', 'DURATION (Weeks)', 'WAITING PERIOD (Days)', and 'ELIGIBILITY REQUIREMENT'. Ensure that these figures comply with Article 9 of the Workers' Compensation Law.
If necessary, attach additional sheets for any other benefits or restrictions that differ from those specified in the law.
Finally, review all entries for accuracy before saving or submitting your completed form through our platform.

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