Nys Ce-200 PDF Form 2023

Nys Ce-200 PDF Form: What You Should Know

Exemption forms may be submitted to any New York State Agency. The New York State Workers and Benefits Administration requests that the following items be provided with the Application Form CE-200: An original and properly executed copy of the form that was completed before the date of application. An original and properly executed copy of the signed, verified copy of the form that was submitted by the applicant. If there is no name and address matching the information you have on file at the time of application, please do not complete the form. Any additional information regarding an applicant's disability must not have been changed, and any change in the applicant's address or name must have occurred prior to the actual filing of the application. (Please see Exemption for New Applicants, above.) Copy of all prior insurance policy documents, including all applicable terms, conditions, and fees. If the applicant's insurance covered injuries or damages sustained outside of New York state, such as those caused by other workers' compensation applicants and/or by another incident of the worker's own negligence, the worker's policy shall not apply to his/her injuries or damages. Copy of the medical certificate from a licensed physician, surgeon, or dentist of the applicant's age or equivalent who was authorized to make the final examination and certification in the case of a child or incapacitated person, which contains a diagnosis as provided by the New York State Department of Health (NYS DOH) as of the date of examination or certification; If the physician certifies that the applicant requires special supervision or care, it shall be accompanied by such documentation of such need as may be required by the New York State Department of Health (NYS DOH). Please send the required documents in one piece to the address listed at the bottom of this application. Failure to submit the required document(s) or to return any of them to NYS DOH upon request may result in the revocation of the certificate of exemption and the applicant being assessed a 350.00 filing fee. Workers' Compensation Administration Attention: Notice of Approval and Certification of Exemption (CE-202) New York State Workers' Compensation Board Citizens of the United States and residents and citizens and non-residents of the United States authorized to travel outside the United States to work as a temporary foreign worker (TOW). NOTE- In certain circumstances, an employee may be covered by workers' compensation insurance from other states.

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