Supplement To Certificate Of Insurance {DB-820.1}

DB-820.1 - SUPPLEMENT TO CERTIFICATE OF INSURANCE. This form is used in the Workers' Compensation Board of the State of New York by employers and insurance carriers to provide additional information regarding disability benefits to eligible employees. It serves as a supplement to the Certificate of Insurance (Form DB-820/829) filed by the employer with the insurance carrier. The form includes sections where the employer and carrier information is filled out, along with details about the benefit amount or rate, maximum duration of benefits, waiting period, eligibility requirements, and employee contributions. The form requires the employer to specify the class or classes of employees covered, the benefit amount or rate payable to employees, the maximum duration of benefits in weeks, the waiting period in days, eligibility requirements for employees, and the employee contribution per week. The form also allows for additional sheets to be attached if necessary and includes a question regarding any other benefits, differences, or restrictions that may exist beyond those specified in the Disability and Paid Family Leave Benefits Law. www.FormsWorkflow.com