New York State Workers' Compensation Board


Please Note

We are a service company that can help you file with the New York State Workers' Compensation Board. We are not associated with this nor any other government agency. We offer paid services and software to help you file. You are not required to purchase our service to file - you may file directly with this agency without using our service.


Contact Information

Physical address:
328 State Street
Schenectady, NY 12305

Phone: 877-632-4996

Web: Home

Licenses

We track the following licenses with the New York State Workers' Compensation Board in order to provide compliance services to our clients. As a client, you see this and other reference data in License Manager in-line with your licenses.

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New York Third Party Administrator License

Agency:New York State Workers' Compensation Board
Eligible Entity Types:
  • a business formed in the State of New York [50(3-b)]
  • a business formed in the State of New York for the sole purpose of administering claims but are not a subsidiary of an insurance carrier licensed to write Workers' Compensation policies [50(3-d)]
  • or, an insurance carrier licensed by the New York State Department of Financial Services to write Workers' Compensation policies in New York State, or a subsidiary of one [50(3-d)]
Foreign Qualification is Prerequisite:Yes
Insurance Requirements:

Provide proof of current insurance policies or exemption:

  • For Workers' Compensation policies, use Certificate of NYS Workers' Compensation Insurance Coverage (Form C-105.2).
  • For Disability Benefits policies, use Certificate of Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law (Form DB-120.1).
  • For Exemption, use Certificate of Attestation of Exemption (Form CE-200).
Bond Requirements:

Self-insurer's Represntative's Bond Form (CE-200)

Notes:

Corporate entities must designate an officer of the corporation as the person responsible for ensuring that the corporate entity complies with all the laws, regulations, policies, procedures, and directives relating to the administration of workers' compensation claims in New York State.

Registered Agent (Special Agency) Required?No

Initial Registration

Form:

TPA Registration Application 

Filing Method:

Email licensing@wcb.ny.gov

Agency Fee:

$0

Law:

NYCRR Section 302-1.2

Before you Apply:
  • Proof of workers' compensations and disability coverage forms (C-105.2 and DB-120.1)
  • Third Party Administrator (TPA) Surety Bond form (OC-407)
  • List of Corporate Officers
  • List of clients represented by the TPA
  • Certificate from NYS DOS

Registration Renewal

Form:

TPA Registration Application (Renewal)

Filing Method:

Email licensing@wcb.ny.gov

Agency Fee:

$0

Due:

Triennially by date of issuance. 

Required Attachments:
  • Proof of workers' compensations and disability coverage forms (C-105.2 and DB-120.1)
  • Third Party Administrator (TPA) Surety Bond form (OC-407)
  • List of Corporate Officers
  • List of clients represented by the TPA
  • Certificate from NYS DOS

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