How to Get and Submit Form C-105.2: NY Workers’ Compensation Certificate

Form C-105.2 is the one-page certificate a private insurance carrier issues to prove a New York business has active workers’ compensation coverage. You do not fill it out yourself. You call your carrier or licensed agent, tell them which government office needs the proof, and they prepare and send the form. That is the whole mechanism, and it only works if you are insured through a private carrier rather than the State Insurance Fund, an approved self-insurance arrangement, or a group self-insurance plan.

When a Government Agency Will Ask for It

Section 57 of the Workers’ Compensation Law prevents any state or municipal department from issuing a permit or license, or entering a contract, connected to work involving employees unless the applicant provides a certificate of insurance in a form the Workers’ Compensation Board chair approves.¹ C-105.2 is one of those approved forms.

Building permits carry a separate rule. Section 125 of the General Municipal Law bars any city, town, or village from issuing a building permit unless the applicant shows proof of both workers’ compensation and disability benefits coverage, or files an affidavit that no employees will do the permitted work.² Almost any construction or renovation triggers this, including a homeowner hiring a contractor.

Make Sure C-105.2 Is the Right Form for You

The Workers’ Compensation Board accepts four different certificates depending on how a business is insured. Requesting the wrong one wastes days.³

C-105.2 if you carry a policy through a private workers’ compensation carrier.
U-26.3 if you are insured through the New York State Insurance Fund. Request this one directly from NYSIF.⁴
SI-12 if you are a Board-approved self-insured employer. Contact the Board’s Self-Insurance Office at selfinsurance@wcb.ny.gov.⁵
SIG-105.2 if you belong to a group self-insurance plan. The group administrator issues it.⁵

A boundary worth knowing: if your business has no employees and is not required to carry coverage, none of these certificates apply. You instead request a Certificate of Attestation of Exemption (CE-200) through the Board’s online system. The CE-200 is only for entities operating in New York without employees, or out-of-state entities whose work takes place entirely outside New York, and it can only be given to a government agency, not to another business or its carrier.⁶

How to Request Form C-105.2 From Your Carrier

You cannot download a blank C-105.2. The form is not posted on the Workers’ Compensation Board’s website, and only private carriers and their licensed agents writing New York workers’ compensation policies are authorized to issue it.⁷⁴

Call your agent, broker, or carrier and tell them you need a C-105.2. The one piece of information they need from you is the name and mailing address of the government office asking for proof, which will appear on the form as the certificate holder. Your carrier already has your policy details and will fill in the rest.⁴

Give yourself time. Most carriers turn certificate requests around in a few business days, but requests can back up during busy construction seasons, or a broker can be slow to relay them. Put the request in as soon as you know which agency needs it, not the day you file the application.

What to Check Before It Goes Out

The C-105.2 is a single page. A sample shows the main fields you should verify against your policy paperwork:⁸

Box 1a, your legal business name and street address exactly as they appear on the policy. P.O. boxes are not accepted here.
Box 1d, your Federal Employer Identification Number, or Social Security Number if you are a sole proprietor.
Box 2, the certificate holder’s name and address.
Box 3, the carrier name, NAIC code or WCB carrier ID number, policy number, and effective dates of coverage.

One box gets overlooked and causes rejections. The form asks whether the carrier will notify the certificate holder if the policy is canceled, within 10 days for non-payment of premium or 30 days for any other reason. Confirm this is marked “Yes.” Many government agencies require cancellation notification as a condition of accepting the certificate.⁹

Ask for the Disability Certificate at the Same Time

Workers’ compensation proof alone is often not enough. Section 125 of the General Municipal Law requires proof of both workers’ compensation and disability benefits coverage for building permits.² The disability and Paid Family Leave equivalent is Form DB-120.1, issued by your disability insurance carrier the same way C-105.2 is.¹⁰

Request both certificates in one call. Submitting them together keeps a permit from stalling because a second document is missing. If your business is exempt from disability coverage, the CE-200 process covers that attestation as well.⁶

How the Form Reaches the Government Agency

Under the Board’s standard procedure, the carrier sends the C-105.2 directly to the certificate holder rather than handing it back to you. Once you provide the agency’s name and mailing address, the carrier mails or transmits the form to that office.³

Some municipal departments also let you upload the certificate through a permit portal or email it to the department directly. If you plan to submit it yourself, confirm the accepted format with the agency first. Either way, follow up a few days later to make sure the document arrived and that the business name, FEIN, and policy dates match the agency’s records. A mismatch in any of those fields will stall an otherwise complete application.

Why Getting This Right Matters

Operating without workers’ compensation coverage carries both civil penalties and criminal liability in New York. The Board can impose civil penalties of up to $2,000 for every 10-day period without coverage, or up to twice the cost of compensation for the payroll during the lapse, whichever is greater. Criminal exposure runs from a misdemeanor for five or fewer employees to a class E felony for more than five, with a class D felony available for a repeat conviction within five years.¹¹ The Board can also issue a stop-work order until coverage is proven and penalties are paid, and an uninsured employer is personally liable for the wage and medical benefits awarded to any injured worker.¹² The certificate is the routine paperwork that keeps a business on the right side of all of this.

1
New York State Senate. New York Workers’ Compensation Code 57 – Restriction on Issue of Permits and the Entering Into Contracts Unless Compensation Is Secured
2
Town of Amherst. Implementing Section 125 of the General Municipal Law
3
New York State Workers’ Compensation Board. Workers’ Compensation Requirements for Government Issued Permits, Licenses, and Contracts
4
New York State Workers’ Compensation Board. Obtaining a C-105.2 Certificate of NYS Workers’ Compensation Insurance
5
New York State Workers’ Compensation Board. Self-Insured Employers Workers’ Compensation Forms
6
New York State Workers’ Compensation Board. Request Certificate of Attestation of Exemption (CE-200)
7
Workers’ Compensation Board. Workers’ Compensation Board All Common Forms
8
New York City Department of Cultural Affairs. C-105.2 New York Workers’ Compensation Form
9
Erie County. Certificate of NYS Workers’ Compensation Insurance Coverage
10
New York State Workers’ Compensation Board. Obtaining a DB-120.1 Certificate of NYS Disability Benefits Insurance
11
New York State Senate. New York Workers’ Compensation Code 52 – Effect of Failure to Secure Compensation
12
New York State Workers’ Compensation Board. Employers Violations of Workers’ Compensation Law (Liability and Penalties)