Application For Self-Insurance (Disability And Paid Family Leave Benefits) {DB-150}

DB-150 - APPLICATION FOR SELF-INSURANCE DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW. An employer may apply for self-Insurance for disability benefits or for disability and paid family leave benefits. An employer may not apply to self-insure for paid family leave benefits only. An application to self-insure is not transferable to subsidiaries or successors. Each entity must file its own application. PLEASE NOTE: Submission of an application does not guarantee approval for self-insurance. Coverage must be maintained until you have received a Notice of Qualification. The undersigned makes application as a self-insurer under Section 211(3) of the Disability and Paid Family Leave Benefits Law of New York State, and makes the following affirmations for the purpose of enabling the Chair. Workers' Compensation Board, to determine that the applicant possesses sufficient financial ability and has adequate resources to render certain the payment of disability or disability and paid family leave benefits to their employees as specified in the Law. Attach a statement of financial condition (Form 10-K or a certified independently audited financial statement). If deemed a candidate for self-insurance, a conditional approval will be issued. Notice of Qualification as a self-insurer will not be issued until all conditions have been met including, but not limited to: submitting and maintaining an adequate security deposit and the submission of an Agreement and Undertaking for Paying Benefits as a Self-Insurer (Form DB-152). www.FormsWorkflow.com