Notice Of Election To Voluntarily Exclude Spouse From Coverage {DB-212.5}

DB-212.5 - NOTICE OF ELECTION TO VOLUNTARILY EXCLUDE SPOUSE FROM COVERAGE PURSUANT TO SECTION 212, SUBDVISION 5 OF THE NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW. This form is used by employers in New York who want to voluntarily exclude their spouse from coverage under the New York State Disability and Paid Family Leave Benefits Law. It allows employers to elect or revoke the exclusion by providing the necessary information and submitting the form to the appropriate party, such as the insurance carrier or the Bureau of Compliance. The form includes instructions and contact information for the Workers' Compensation Board. www.FormsWorkflow.com