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.
Termination box: complete D if TERMINATION box is checked at top of form (attach DB-118 if employer is terminating status as covered employer).
| Question | Answer |
|---|---|
| Form Name | Form DB-802 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 57 |
| Avg. time to fill out | 10 min |
| Edition | 1-24 |
| Issuing agency | State of New York Workers' Compensation Board |
| Where to send | Workers' Compensation Board Plans Acceptance Unit |
| Who files | An association of employers or employees, union or trustees |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | DB-802, DB 802, DB802, Form DB-802, NY DB-802, Application to Have Association, Union or Trustees Plan Accepted/Terminated as Employer's Plan |
| Official source | Form DB-802 (Rev 1-24), State of New York Workers' Compensation Board |
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