U-26.3 - New York State Insurance Fund Certificate of Workers’ Compensation
Coverage
What is the U-26.3 form?
Who provides the U-26.3 form?
Why it is needed?
When is it needed?
Who is the certificate holder?
Acceptable proof that the business has workers’ compensation coverage through the New York State Insurance Fund. The U-26.3 is only available through from the New York State Insurance Fund.* To establish proof that a business has secured workers’ compensation insurance coverage for all its employees.
Prior to any permit being issued or any contract, including purchase orders, being entered into for work
The Research Foundation for The State
University of New York
Who are the additional insureds? |
N/A |
*The U-26.3 can be obtained from any Business Office of the New York State Insurance Fund.
Workers’ compensation insurance is required for a business in which employees are engaged in hazardous employment as defined under article 1, section 3 of the New York State Workers’ Compensation law.
The Workers' Compensation Law requires employers to post Form C-105, Notice of Compliance - Workers’ Compensation Law, in all business locations. Employers involved in moving household goods or furniture and/or employers who have no established business locations for employees are required to post a Notice of Compliance, C-105.1, in vehicles they own or operate. The C-105 and the C-105.1 can be obtained from the State Insurance Fund and was also provided in the renewal information package that employers receive.
All NYS licensed workers’ compensation carriers issue the C-105.2, Certificate of NYS Workers’ Compensation Insurance Coverage, which is equivalent to the U-26.3 New York State Insurance Fund Certificate of Workers’ Compensation Coverage.
The next page provides a sample of a U-26.3 - New York State Insurance Fund Certificate of Workers’ Compensation Coverage.
New York State Insurance Fund
Workers' Compensation & Disability Benefits Specialists Since 1914
199 CHURCH STREET, NEW YORK, N.Y. 10007-1100
Phone: (888) 997-3863
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
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POLICYHOLDER |
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CERTIFICATE HOLDER |
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STATE UNIVERSITY OF NEW YORK @ |
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ALBAYATTN:' |
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1400 WASHINGTON AVENUE |
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ALBANY NY 12222 |
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POLICY NUMBER |
CERTIFICATE NUMBER |
PERIOD COVERED BY THIS CERTIFICATE |
DATE |
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01/01/2009 TO 05/01/2010 |
1/8/2009 |
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY N0.2058 840-6 UNTIL 05/01/2010, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS’ COMPENSATION UNDER THE NEW YORK WORKERS’ COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW.
IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 05/01/2010 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE,
10DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW
YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE.
THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY..
NEW YORK STATE INSURANCE FUND
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DIRECTOR,INSURANCE FUND UNDERWRITING |
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This certificate can be validated on our web site at https://www.nysif.com/cert/certval .asp or by calling (888) 875-5790 |
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VALIDATION NUMBER: 107031806 |
U-26 3 |
0/CD23592-21/94 |
