Form Db 802 PDF Details

In the dynamic landscape of employment and labor regulations in New York, navigating through the complexities of compliance can be a daunting task for associations, unions, and trustees handling employer plans. Central to this challenge is the DB-802 form, a critical document under the purview of the New York State Workers' Compensation Board. This form serves as an application for these entities to have their disability and paid family leave benefits plans either accepted or terminated as an employer's plan. Whether it’s for an initial setup, a termination, reinstatement, or to supersede an existing arrangement, the DB-802 requires meticulous attention to detail across its various sections, including employer information, plan details, and the specifics of the coverage provided. The provisions laid out in the form outline not just the obligations of the employer towards their employees concerning disability and paid family leave benefits, but also the responsibilities and the certification process that associations, unions, or trustees must adhere to. Moreover, the form addresses the conditions under which an employer's plan may be modified or discontinued, emphasizing the need for transparency and accuracy in reporting to the Workers' Compensation Board. The completion and submission of this form, hence, are not just procedural but underscore a commitment to the welfare of employees, ensuring they are covered adequately by their employer's plan.

QuestionAnswer
Form NameForm Db 802
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesny dmv forms 802, db 802 form, ny db 802 form, ny db802 fillable

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STATE OF NEW YORK WORKERS' COMPENSATION BOARD

DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW

APPLICATION TO HAVE ASSOCIATION, UNION OR TRUSTEES PLAN

ACCEPTED/TERMINATED AS EMPLOYER'S PLAN

An association of employers or employees, union or trustees shall file this application with/without an Employer.

Initial

Termination

Reinstatement

Supersedes

Transaction Effective Date:

SECTIONS A, B and C MUST ALWAYS BE COMPLETED.

Initial: Sections A, B, C, F and G (Employer's Certification on reverse) must be completed.

Terminations: Sections A, B, C, D and F must be completed.

Reinstatements: Sections A, B, C and F must be completed.

Supersedes: Sections A, B, C, E and F must be completed.

A. CURRENT EMPLOYER INFORMATION

1. EMPLOYER'S LEGAL NAME, INCLUDING (DBA/AKA/TA)

4. EMPLOYER FEIN

2. EMPLOYER STREET ADDRESS

5. NUMBER (#) OF EMPLOYEES

3. EMPLOYER CITY, STATE and ZIP CODE

6. TELEPHONE NUMBER

B. PLAN INFORMATION

7. WCB PLAN NUMBER

8. EFFECTIVE DATE OF COVERAGE

9. Plan Coverage

 

Self-Insurance

Insurance Carrier

10. NAME OF ASSOCATION, UNION OR TRUSTEES PLAN

11. NAME AND CARRIER IDENTIFICATION NUMBER (If Plan coverage through carrier)

12. INSURANCE POLICY NUMBER (If applicable)

 

 

C. COVERAGE

a. The policy provides coverage for:

Both disability and paid family leave benefits

Disability benefits only

Paid family leave benefits only

b. The policy covers the following class or classes of employees:

All employees

All employees eligible for benefits under the Law, except those classes of employees eligible to receive benefits under another policy or plan accepted by the Chair.

Only the class or classes of employees listed here:

D.Complete if TERMINATION box is checked at top of form (attach DB-118 if employer is terminating status as covered employer)

Non-Payment of Premium

Other:

Not Subject/No Eligible Employees

Date:

 

 

Out of Business

Date:

 

DATE CANCELLATION OR

 

TERMINATION SENT TO EMPLOYER:

Seasonal

Date:

 

 

 

E.Complete if SUPERSEDES box is checked at top of form

Reason(s) for modification:

F. CERTIFICATION BY ASSOCATION, UNION OR TRUSTEES

I certify that the above information is true, and agree that during the term of the Plan as accepted by the Chair of the Workers' Compensation Board, the EMPLOYER'S participation will continue to be effective until ten days after a written notice of termination is served on the EMPLOYER and filed with the Chair of the Workers' Compensation Board by or on behalf of the Association, Union or Trustees.

Date Signed

By

 

 

 

 

 

 

Signature of Association, Union or Trustee Official

Telephone Number

 

 

 

Name and Title

 

DB-802 (10-17)

G. INITIAL CERTIFICATION BY EMPLOYER

State of New York

County of

being duly sworn, deposes and says:

A. The EMPLOYER requests acceptance of this PLAN identified by WCB Plan Number

of

 

as the EMPLOYER'S Plan.

Association, Union or Trustees

B. The EMPLOYER agrees:

1.That all eligible employees will be provided Benefits either by the Plan or in one or more of the ways specified in Sec. 211 of the Disability and Paid Family Leave Benefits Law.

2.That any excess of the aggregate contributions of employees over the cost of providing Benefits and any uncommitted balance of employee contributions remaining at the termination of this Plan shall be distributed or applied for the sole benefit of employees or otherwise be applied or disposed of pursuant to Sec. 210, subdivision 4, and Sec. 216 of the Disability and Paid Family Leave Benefits Law.

3.That unless paid by the Association, Union or Trustees, the employer will pay all assessments to the special fund under Sec. 214 of the Workers' Compensation Law and all assessments for expenses of administration under Sec. 228.

4.That the Plan Benefits will be continued until the Employer has filed written notice with the Chair of the termination of the Plan.

 

 

 

 

 

 

Employer

Date Signed

By

 

 

 

 

 

 

 

 

Signature of Owner, Partner or Authorized Officer

Telephone Number

 

Name and Title

 

Sworn to before me this

 

 

 

 

day of

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Notary Public

EMAIL COMPLETED FORM AND ATTACHMENTS TO PAU@WCB.NY.GOV

OR MAIL COMPLETED FORM AND ATTACHMENTS TO:

WORKERS' COMPENSATION BOARD

PLANS ACCEPTANCE UNIT

PO BOX 5200

BINGHAMTON, NY 13902-5200

DB-802 (10-17) REVERSE

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

How to Edit Form Db 802 Online for Free

Using the online PDF tool by FormsPal, you'll be able to fill in or modify db 802 right here. The tool is continually updated by our team, getting cool functions and growing to be better. Starting is effortless! All you should do is adhere to the following basic steps directly below:

Step 1: Simply click the "Get Form Button" in the top section of this page to open our form editor. This way, you'll find everything that is required to work with your file.

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When it comes to blank fields of this precise document, here is what you should know:

1. Whenever submitting the db 802, make sure to incorporate all essential blanks within its associated section. This will help to expedite the work, enabling your information to be handled quickly and properly.

db 802 form completion process clarified (portion 1)

2. Once the previous part is completed, you should add the required specifics in Both disability and paid family, All employees, Disability benefits only, Paid family leave benefits only, All employees eligible for, Only the class or classes of, D Complete if TERMINATION box is, NonPayment of Premium, Other, Not SubjectNo Eligible Employees, Date, Out of Business, Seasonal, Date, and Date so you can move forward further.

db 802 form completion process explained (stage 2)

In terms of Date and Disability benefits only, make sure that you get them right in this section. Those two are viewed as the key ones in the form.

3. This subsequent part is considered quite easy, - every one of these empty fields needs to be completed here.

this field, next field, and other fields in db 802 form

4. This next section requires some additional information. Ensure you complete all the necessary fields - INITIAL CERTIFICATION BY EMPLOYER, State of New York County of, being duly sworn deposes and says, A The EMPLOYER requests acceptance, as the EMPLOYERS Plan, Association Union or Trustees, B The EMPLOYER agrees That all, Disability and Paid Family Leave, That any excess of the aggregate, That unless paid by the, the Workers Compensation Law and, and That the Plan Benefits will be - to proceed further in your process!

db 802 form conclusion process described (portion 4)

5. To wrap up your document, the last section requires a few extra fields. Filling in Date Signed, Employer, Telephone Number, Name and Title, Signature of Owner Partner or, Sworn to before me this, day of, Signature of Notary Public, EMAIL COMPLETED FORM AND, OR MAIL COMPLETED FORM AND, WORKERS COMPENSATION BOARD, PLANS ACCEPTANCE UNIT, PO BOX, and BINGHAMTON NY will certainly conclude everything and you will be done in the blink of an eye!

Tips to prepare db 802 form step 5

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