Cold Spring, NY · Putnam County
Workers’ Compensation and Disability Benefits Insurance Affidavit
This sworn WC/DB-100 affidavit lets an eligible business or homeowner state that New York workers’ compensation and/or disability benefits insurance coverage is not required when applying for a government permit, license, or contract.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
The applicant identifies the business and government permit, license, or contract, then checks the form’s applicable reasons for stating that New York workers’ compensation and/or disability benefits insurance is not required. The form says it may be used only to show a government entity, not another business or its insurer. The applicant must have it notarized, send it to the Workers’ Compensation Board for a received stamp, then provide the stamped form to the government entity.
Who needs it
A business or homeowner applying for a government permit, license, or contract may use this form if they can truthfully meet one of its listed coverage-exemption reasons.
Why it needs a notary
The form has a sworn affidavit block marked “Sworn to before me”; the applicant signs the affidavit before a notary public.
How to get this notarized
- 1
Download The Affidavit
Get the WC/DB-100 Workers’ Compensation and Disability Benefits Insurance Affidavit.
- 2
Fill In The Form
Enter the applicant, business, and permit details, and check the applicable coverage-exemption reasons. Attach any required supporting sheets or certificate.
- 3
Book An Online Notary
Arrange a session with a commissioned online notary to notarize the sworn statement.
- 4
Sign On Video
Sign the affidavit during the remote session as directed by the notary.
- 5
Send It For Stamping
Fax or mail the completed, notarized form to the closest New York State Workers’ Compensation Board office.
- 6
Submit It To The Government Entity
After the Board returns the stamped affidavit, provide a copy or original to the government entity handling your permit, license, or contract.
Preview the form
The blank PDF straight from Cold Spring. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I submit the completed WC/DB-100 affidavit?
- First have the statement notarized, then fax or mail the completed form to the closest New York State Workers’ Compensation Board office. After it is stamped and returned, provide a copy or original to the government entity, as required.
- Do I need to send the affidavit to the Workers’ Compensation Board before the city?
- Yes. The form says it must be notarized and sent to the Workers’ Compensation Board for a received stamp before you provide it to the government entity handling your permit, license, or contract.
- Can I notarize this affidavit online?
- New York authorizes its notaries to perform remote online notarizations under Executive Law §135-c. Confirm with the city, town or village if unsure whether the receiving government entity will accept the online-notarized affidavit.
- Who can use this affidavit?
- The form is for eligible New York entities with no employees and certain out-of-state entities. It may be used only to show a government entity that specified New York insurance coverage is not required—not to show another business or its insurer.
Other forms in Cold Spring
Workers’ Compensation and Disability Benefits Insurance Affidavit in other New York cities
Each city publishes its own version of this form. Pick the city where you’re filing.