Northumberland, NY · Saratoga County
Workers’ Compensation and Disability Benefits Insurance Affidavit
This sworn affidavit lets a 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 WC/DB-100 affidavit asks an applicant to identify the business, the government permit, license, or contract involved, and the stated basis for claiming that workers’ compensation and/or disability benefits coverage is not required. The applicant must complete the applicable statements, sign under oath before a notary, then send the form to the closest Workers’ Compensation Board office for a received stamp. Provide the stamped form to the government entity when requested; a city may require it as part of a permit, license, or contract application.
Who needs it
A business or homeowner applying for a government permit, license, or contract may need this affidavit if claiming the specified New York insurance coverage is not required.
How to get this notarized
- 1
Download The Affidavit
Get the WC/DB-100 affidavit for New York entities and qualifying out-of-state entities with no employees.
- 2
Complete The Applicable Sections
Enter the applicant, business, and government application details, then check only the statements that truthfully apply.
- 3
Book An Online Notary
Arrange a session with a commissioned online notary for the affidavit’s sworn signing.
- 4
Sign On Video
Appear for the remote session and sign and swear to the affidavit before the notary.
- 5
Submit The Notarized Form
Fax or mail the completed form to the closest Workers’ Compensation Board office for a received stamp, then provide it to the government entity as requested.
Preview the form
The blank PDF straight from Northumberland. 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 complete and submit the WC/DB-100 affidavit?
- Fill in the applicant and business details, select the applicable statements, and sign before a notary. Then fax or mail the completed, notarized form to the closest Workers’ Compensation Board office for a received stamp, and provide the stamped form to the government entity as requested.
- Do I need to notarize this form before sending it to the Workers’ Compensation Board?
- Yes. The form says the statement must first be notarized and then sent to the Workers’ Compensation Board to be stamped as received. Incomplete forms are returned unstamped.
- Can I use a commissioned online notary for this affidavit?
- New York authorizes remote online notarization by its own notaries under Executive Law §135-c. You can use a commissioned online notary for the sworn signing; check that you can complete the required video session and provide the notarized form for submission.
- Does the stamped affidavit replace insurance coverage or apply to other businesses?
- No. The form says it cannot waive any party’s workers’ compensation rights or obligations and may only be used to show a government entity that the specified New York coverage is not required. It cannot be used to make that showing to other businesses or their insurance carriers.
- When does the Workers’ Compensation Board stamp expire for government use?
- The form states that government officials will not accept the affidavit one year after the date the Workers’ Compensation Board stamped it as received. Confirm with the city, town or village if unsure.