Application For Acceptance Of Insurance Form {DB-850}

The form as issued will include variable (fill-in provisions). When coverage under this form is provided for an employer the certificate of insurance will, by specific reference, and in the same order as listed in the insurance form, indicate the variable (fill-in) provisions contained in the insurance contract as issued. Other benefits not related to disability and/or paid family leave benefits are to be provided, such as group life, dependent benefits, etc. The benefits to be provided are the same in all respects and greater in one or more respects than required by Section 204 of the Workers' Compensation Law. STATE OF NEW YORK WORKERS' COMPENSATION BOARD Bureau of Compliance l PO BOX 5200, Binghamton, NY 13902-5200 APPLICATION FOR ACCEPTANCE OF INSURANCE FORM Under Section 360.1(b)(1) NYCRRDB-850 (10-17) Policy Other (specify) Supplement Rider or EndorsementTo: Chair, Workers' Compensation Board , an insurance carrierauthorized by the Superintendent of Financial Services to write contracts insuring the obligations of employers pursuant to Section 211 of the Workers' Compensation Law, hereby applies under Section 360.1(b)(1) NYCRR for the acceptance of the attached insurance form, and requests assignment of an identifying number.1.The attached form is: The benefits to be provided are the same in all respects as those required by Section 204 of the Workers' Compensation Law.4.The following item or items, as checked, correctly describe the form herewith submitted. 2.This form was filed with the Superintendent of Financial Services on Insurance Carrier's Form No. Other benefits related to disability benefits are to be provided, such as hospital, medical, surgical, etc.3.The above insurance form, if other than a Policy form, will be used with the insurance carrier form(s) identified below. (Listinsurance carrier form number and Workers' Compensation Board identifying number, if any.)5.The insurance carrier will, pursuant to Section 360.1(b)(1) NYCRR, and until acceptance of this insurance form has been revokedby the Chair or approved thereof rescinded by the Superintendent of Financial Services, file promptly the certificate of insuranceas prescribed by the Chair for each insurance contract issued using this form. Date Telephone Number Title By(Signature of Authorized Representative) SEE INSTRUCTIONS and NOTICE OF ACCEPTANCE ON REVERSE American LegalNet, Inc. www.FormsWorkFlow.com By Date of AcceptanceAuthorized SignatureUntil further notice the attached insurance form is assigned the above WCB Identifying Number. Acceptance of insurance forms is subject to the requirement that adequate facilities for promptly and efficiently servicing insured claims shall be provided and maintained by the carrier in locations convenient to every part of the state where there are places of employment of employers who provide benefits for employees by an insurance contract of the carrier. The insurance form identified above is accepted for use within the limitations described in the application submitted by the insurance carrier and subject to the provisions of Article 9 of the Workers' Compensation Law and Regulations thereunder.DB-850 (10-17) REVERSE THIS ACCEPTANCE IS VALID ONLY WHEN COUNTERSIGNED AND BOARD SEAL IS AFFIXED.INSTRUCTIONS 1.This application may be signed only by a representative authorized to act for the Insurance Carrier in matters relating to theacceptance of insurance forms under the NYS Disability and Paid Family Leave Benefits Law. 2.For each insurance form submitted to the Chair for acceptance, prepare a separate application and attach it firmly to thecorresponding insurance form. When accepted, a duplicate application with appropriate notation of acceptance by the Chair above, will be returned to the insurance carrier. Insurance Carrier WCB Identifying No. Insurance Carrier Form No.NOTICE OF ACCEPTANCE OF INSURANCE FORMSTHIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION EMAIL COMPLETED FORM AND ATTACHMENTS TO PAU@WCB.NY.GOV OR MAIL COMPLETED FORM AND ATTACHMENTS TO: WORKERS' COMPENSATION BOARD PLANS ACCEPTANCE UNIT PO BOX 5200 BINGHAMTON, NY 13902-5200 American LegalNet, Inc. www.FormsWorkFlow.com