State of New York – Workers’ Compensation Board CONSENT TO NYS WORKERS' COMPENSATION BOARD JURISDICTION FOR NON-NEW YORK LICENSED CARRIERS (3C COVERAGE) Know All Men by these Presents: That the ________________________________________________________________________ Insurance Corporation is a _____________________________________ insurance corporation duly organized under and by virtue of the laws of the State of _________________________________ having its principal place of business in _________________________________________ in the State of ____________________________________________ and duly authorized to do business in ______________________________________ and appointed, does hereby agree to be subject to the jurisdiction of the New York State Workers’ Compensation Board (WCB), and the courts of the State of New York, to be bound by their rulings and decisions, in any administrative or judicial proceedings arising out of a claim filed by an employee with the WCB for benefits under the New York Workers’ Compensation Law over which the WCB has subject matter jurisdiction, where the employer of such employee holds a policy from ___________ Insurance Corporation for workers’ compensation coverage for injuries, diseases and death in New York State that includes extraterritorial coverage provided under item 3C of ___________________ Insurance Corporation’s workers’ compensation policy, an exemplar of which is appended as Exhibit A to this Statement. _______________________________ Insurance Corporation does hereby make, constitute and appoint the Secretary to the WCB its true and lawful attorney in the State of New York, on whom service of process, against said company, may be made in any administrative or judicial proceeding arising out of a claim for benefits under the Workers’ Compensation Law in the State of New York. Said attorney is hereby authorized and empowered to receive and accept such service of process and such service shall be taken and held as valid as if served upon said company. That the coverage afforded by the policies of such corporation, including extraterritorial coverage provided under item 3C of the policy attached as Exhibit A will provide all coverage required by the Workers’ Compensation Law, in accordance with all governing statutes, regulations and policies of the WCB, and to thereby provide coverage under the laws of New York State. Such coverage shall not entail compliance with any requirements of the New York Workers' Compensation Law not related to the payment of claims, including any requirements regarding reporting or the payment of assessments. This statement does not constitute an agreement to pay any claims arising out of residual coverage which the _________________________ Insurance Corporation provides under a requirement of the laws of the State of ________________, and which do not encompass coverage under item 3C of ______________________ Insurance Corporation's workers' compensation policy. Except as precluded by the above _______________________ Insurance Corporation may raise any defenses valid under the laws of New York State. This statement shall be valid until expressly revoked in writing, provided any such revocation shall not apply to any claims that arose prior to the date of such revocation. The undersigned understands that the WCB may decline to accept this statement as evidence that it is providing coverage under the laws of New York State, and in its discretion at any time, upon 10 days notice to the carrier, revoke its acceptance of this statement. C-105.11 (11-10) (OVER) American LegalNet, Inc. www.FormsWorkFlow.com IN WITNESS WHEREOF, _______________________________________ insurance corporation in pursuance of a resolution duly adopted by its Board of Directors, has caused this instrument to be executed in its name by its President and Secretary, and its corporate seal to be hereto affixed this ____________________________ day of ___________________________ 20______. ________________________________________ Insurance Corporation By________________________________________ (President) (Seal) _________________________________________ (Secretary) State of _______________________ ) ) ss: County of _____________________ ) I, ___________________________________________, a Notary Public in and for the County and State aforesaid, do hereby certify that ___________________________________________ and, ______________________________________ personally known to me to be the President and Secretary, respectively, of the ________________________________________________ Insurance Corporation, and known to me to be the same persons whose names are subscribed to the foregoing instrument, appeared before me this day in person, and acknowledged that they signed, sealed and delivered this instrument as their free and voluntary act and as the free and voluntary act and deed of said insurance corporation for the uses and purposes therein set forth. And the said _______________________________, Secretary of said insurance corporation, did then and there acknowledge and declare that s/he had affixed thereto the Corporate Seal of said _____________________________ insurance company pursuant to the authority granted to him by the By-Laws of said _________________________________________ insurance corporation, and had appended a certified copy of such by-laws and the authorizing resolution of the Board of Directors. Given under by hand and Notarial Seal, this _______________ day of _______________ 20 ___. __________________________________________________________ (Notary Public) C-105.11 (Reverse) American LegalNet, Inc. www.FormsWorkFlow.com