New York > Workers Compensation
Notice Of Election To Voluntarily Exclude Spouse From Coverage DB-212.5 - New York
| Notice Of Election To Voluntarily Exclude Spouse From Coverage Form. This is a New York form and can be used in Workers Compensation . |
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STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. NOTICE OF ELECTION TO VOLUNTARILY EXCLUDE SPOUSE FROM COVERAGE PURSUANT TO SECTION 212, SUBDIVISION 5 OF THE DISABILITY BENEFITS LAW INSTRUCTIONS: Sole-proprietorships, regular partnerships, individual trustees, individual receivers and legal representatives may be eligible for spousal exemptions. Corporations, LLCs, LLPs, LPs, PLLCs, PLLPs, RLLCs, RLLPs, Joint Ventures, associations, unions, and nonprofits are NOT eligible for spousal exemptions. 1. If the employer has other employees and disability coverage through an insurance policy, complete and file this form with the insurance carrier. 2. If the employer has no other employees or is an approved self-insurer, complete and file this form with the Disability Benefits Bureau, 100 Broadway-Menands, Albany, NY 12241-0005. To: TAKE NOTICE that under the provisions of Section 212, subdivision 5 of the New York Disability Benefits Law the employer named below elects to exclude his or her spouse named below from coverage under the New York Disability Benefits Law. If the employer provides disability benefits to his or her employees through an insurance policy, such exclusion will be applicable with respect to all policies issued to the employer by the above named insurance carrier as long as it shall continuously insure the employer. Name of employer__________________________________________________________________ Unemployment Insurance Employer Registration No.____________________________ Address of Employer________________________________________________________________ Name of Spouse Excluded from Policy__________________________________________________ Social Security No. of spouse___ ___ ___--___ ___ --___ ___ ___ ___ Date ________________________By__________________________________________________ Telephone No. (____)______________________ NOTE: THIS ELECTION IS FINAL AND BINDING UPON THE SPOUSE NAMED IN THIS NOTICE UNTIL REVOKED BY THE EMPLOYER. SEE REVERSE SIDE FOR COPY OF RELEVANT PORTION OF SECTION 212, SUBDIVISION 5 OF THE DISABILITY BENEFITS LAW. DB-212.5 (11-06) Prescribed by Chair Workers' Compensation Board State of New York www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkflow.com Section 212, Subdivision 5 of the New York Disability Benefits Law Section 212, Subdivision 5. "A spouse who is an employee of a covered employer shall be deemed to be included in the employer's disability benefits insurance contract or covered by a certificate of self-insurance or a plan under section two hundred eleven of this article, unless the employer elects to exclude such spouse from the coverage of this article. Such election shall be made by any such employer filing with the insurance carrier, or the chair of the workers' compensation board in the case of self-insurance, upon a form prescribed by the chair, a notice that the employer elects to exclude such spouse named in the notice from the coverage of this article. Such election shall be effective with respect to all policies issued to such employer by such insurance carrier as long as it shall continuously insure the employer. Such election shall be final and binding upon the spouse named in the notice until revoked by the employer." DB-212.5 (11-06)Reverse American LegalNet, Inc. www.FormsWorkflow.com
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