Workers’ Compensation Coverage or NYS Exemption

Which path applies to you?

• Contractor with employees → Submit proof of coverage.
• NYSIF policyholder → Your proof is a U-26.3 form.
• Self-insured employer → Your proof is an SI-12/equivalent.
• Contractor with no employees or homeowner doing own work → Request a CE-200 exemption for this job.

ACORD certificates are not acceptable proof in New York State.

Have coverage? Submit these with your permit

1. Workers’ Compensation proof (choose one):
   • C-105.2 – Certificate of NYS Workers’ Compensation Insurance
   • U-26.3 – NYS Insurance Fund Certificate
   • Self-Insurance certificate (SI-12 or applicable)
2. Disability & Paid Family Leave proof:
   • DB-120.1 – Certificate of Disability & Paid Family Leave Insurance
3. Attach to your permit application and submit to the Town of Newcomb Code Enforcement Office.

Verify your legal business name on the certificates matches your permit application.

No employees? Request a CE-200 (job-specific)

1. Request CE-200 online
2. When prompted, select the option that applies (no employees / homeowner doing own work).
3. Important: CE-200 certificates are permit- and job-specific. Obtain a separate CE-200 for each building permit.
4. Upload or deliver the CE-200 with your permit application.

The CE-200 attests that insurance is not required for the specific permit, license, or contract.

Frequently Asked Questions

Are ACORD certificates acceptable?

No. New York State does not accept ACORD forms as proof of Workers’ Compensation or Disability & Paid Family Leave coverage. Accepted forms are listed above.

Homeowner projects

Homeowners performing their own work may use the CE-200 if they have no employees. If workers are hired or the situation changes, coverage is required.

What if I’m self-insured?

Self-insured employers must submit appropriate self-insurance certificates (e.g., SI-12 or as applicable) along with permit materials.

Need help?

Visit the NYS Workers’ Compensation Board or contact the Town of Newcomb Code Enforcement Office below.

Quick Submission Checklist

• Workers’ Compensation proof (C-105.2, U-26.3, or Self-Insurance) or CE-200 exemption
• DB-120.1 (Disability & Paid Family Leave)
• Matches business/legal name on permit application
• Include with building permit application