New York > Workers Compensation
Application For Acceptance Of Insurance Form DB-850 - New York
| Application For Acceptance Of Insurance Form Form. This is a New York form and can be used in Workers Compensation . |
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WORKERS' COMPENSATION BOARD DISABILITY BENEFITS BUREAU 100 BROADWAY-MENANDS ALBANY, NY 12241-0005 STATE OF NEW YORK APPLICATION FOR ACCEPTANCE OF INSURANCE FORM Under Section 360.1(b)(1) NYCRR To: Chair, Workers' Compensation Board _____________________________________________________________________________________, an insurance carrier authorized by the Superintendent of Insurance 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: Policy Rider or Endorsement Supplement Other (specify) ________________________________________________________ 2. This form was filed with the Superintendent of Insurance on _________________ Insurance Carrier's Form No._______________ 3. The above insurance form, if other than a Policy form, will be used with insurance carrier form(s) identified below. (List insurance carrier form number and Workers' Compensation Board identifying number, if any.) ___________________________________________________________________________________________ 4. The following item or items, as checked, correctly describe the form herewith submitted. a. The benefits to be provided are the same in all respects as those required by Section 204 of the Workers' Compensation Law. 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. Other benefits related to disability benefits are to be provided, such as hospital, medical, surgical, etc. Other benefits not related to disability benefits are to be provided, such as group life, dependent benefits, etc. 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. b. c. d. e. 5. The insurance carrier will, pursuant to Section 360.1(b)(1) NYCRR, and until acceptance of this insurance form has been revoked by the Chair or approval thereof rescinded by the Superintendent of Insurance, file promptly the certificate of insurance as prescribed by the Chair for each insurance contract issued using this form. Date:________________________________ By:____________________________________________________ Signature of Authorized Representative Tel. Number:__________________________ Title:___________________________________________________ DB-850 (3-02) Notice of Acceptance See Instructions on Reverse Side NOTICE OF ACCEPTANCE OF INSURANCE FORMS Insurance Carrier_________________________________________________________________________________________ W.C.B. Identifying No.___________________________ Insurance Carrier Form No.___________________________ Until further notice the attached insurance form is assigned the above W.C.B. 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. _______________________________ Date of Acceptance By_______________________________________ Authorized Signature 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 the acceptance of insurance forms under the Disability Benefits Law. 2. For each insurance form submitted to the Chair for acceptance: a. Prepare a separate application in duplicate, and attach firmly to each copy of the insurance form. b. Enclose four (4) extra copies of the insurance form with the application. 3. Mail completed application and copies of the insurance form to: WORKERS' COMPENSATION BOARD DISABILITY BENEFITS BUREAU 100 BROADWAY-MENANDS ALBANY, NY. 12241-0005 When accepted, duplicate application with appropriate notation of acceptance by the Chair above, will be returned to the insurance carrier. THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. DB-850 (3-02) Reverse www.wcb.state.ny.us
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