Certificate of NYS Workers' Compensation Insurance Coverage 2025

1. Click ‘Get Form’ to open the Certificate of NYS Workers' Compensation Insurance Coverage in our editor.
2. Begin by entering the Legal Name & Address of the Insured in section 1a. Ensure you use only the street address for accuracy.
3. In section 1b, provide the Business Telephone Number of the Insured to facilitate communication.
4. Fill in section 1c with the NYS Unemployment Insurance Employer Registration Number of the Insured for identification purposes.
5. If applicable, specify the Work Location of the Insured in section 1d, particularly if coverage is limited to certain locations.
6. In section 2, enter the Name and Address of the Entity Requesting Proof of Coverage, ensuring it matches official records.
7. Complete sections 3a through 3d by providing details about the Insurance Carrier, Policy Number, effective period, and any exclusions regarding Proprietors or Partners.
8. Finally, ensure that an authorized representative signs and dates at the bottom to validate this certificate before submission.

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