The Monroe County Department of Public Health is required to ensure that permit applicants are in compliance with New York State Workers' Compensation/Disability requirements at the time a permit is issued.  ACORD forms are not acceptable documentation.  

Links to examples of the various forms: 

• Two page document with small version of all forms

Examples of acceptable Workers' Compensation certificates:

• C-105.2 Certificate of NYS Workers' Compensation Insurance Coverage
• U-26.3 Certificate of Workers' Compensation Insurance
• SI-12 Self-Insurance Certification
• GSI-105.2 Certificate of Participation in Workers' Compensation Group Self-Insurance

Examples of acceptable Disability Coverage documentation:

• DB-120.1 Certificate of Insurance Coverage under the NYS Disability Benefits Law
• DB-155 Compliance with Disability Benefits Law (Self-Insurance) 

Example of an exemption from Workers' Compensation, Disability, or both Workers' Compensation and Disability:

• CE-200 Certificate of Attestation of Exemption

Entities eligible for an exemption can request a Certificate of Attestation of Exemption through the Workers' Compensation website

• Apply online for a CE-200

For details about this requirement, see the NY Workers' Compensation Board's publication:

• NY State Workers' Compensation Board Prove It to Move It

If you have questions, please contact the relevant program.