Do I need a notary for the Workers’ Compensation Exemption Certificate Application?

No. The application has a signature and date line but no notary block. The signer affirms the information under penalties of perjury.

How do I submit the Workers’ Compensation Exemption Certificate Application?

Mail it to the Workers’ Compensation Board Bureau of Compliance at the address in the form or fax it to 518-486-7145. The form also describes an online application.

Who can apply for an exemption certificate?

Eligibility depends on the applicant’s circumstances. The application lists reasons for workers’ compensation and disability benefits exemptions; review its instructions before applying.

What information does the application ask for?

It asks for applicant and legal entity information, permit, license, or contract details, job-site information when applicable, and the reason for claiming exemption.

Pawling, NY · Dutchess County

No notary required

Workers’ Compensation Exemption Certificate Application

This application is for eligible businesses and homeowners seeking a certificate of exemption from workers’ compensation and/or disability benefits insurance coverage.

What this form is

Use this application to request a certificate stating that an applicant seeking a government permit, license, or contract is not required to carry workers’ compensation and/or disability benefits insurance. The application asks for applicant and business details, permit or contract information, job-site details when applicable, and the reason for claiming exemption. Complete it in full and submit it to the Workers’ Compensation Board.

Who needs it

Eligible businesses or homeowners seeking a permit, license, or contract from a government entity may use this application to request an exemption certificate.

How to submit it

Mail the completed application to the Workers’ Compensation Board Bureau of Compliance, CE-200, 100 Broadway, Albany, NY 12241-0005, or fax it to 518-486-7145. The form also directs applicants to the Board’s online application for immediate printing.

About notarization

This application is signed and dated without a notary; the signer affirms the information under penalties of perjury.

How to submit this form

1
Download The Application
Download the application and review the separate CE-200 instructions before completing it.
2
Complete The Application
Fill in all applicable sections, including applicant, business, permit or contract, and exemption information.
3
Gather Required Details
Include job-site details for a building permit application and any additional information required by the exemption option selected.
4
Submit To The Board
Mail the completed application to the Workers’ Compensation Board Bureau of Compliance or fax it to 518-486-7145.

Frequently asked questions

Do I need a notary for the Workers’ Compensation Exemption Certificate Application?: No. The application has a signature and date line but no notary block. The signer affirms the information under penalties of perjury.
How do I submit the Workers’ Compensation Exemption Certificate Application?: Mail it to the Workers’ Compensation Board Bureau of Compliance at the address in the form or fax it to 518-486-7145. The form also describes an online application.
Who can apply for an exemption certificate?: Eligibility depends on the applicant’s circumstances. The application lists reasons for workers’ compensation and disability benefits exemptions; review its instructions before applying.
What information does the application ask for?: It asks for applicant and legal entity information, permit, license, or contract details, job-site information when applicable, and the reason for claiming exemption.

Need something notarized?

This Workers’ Compensation Exemption Certificate Application doesn’t need a notary — but if you have another Pawling form that does, a commissioned online notary can help.