9. Plan CoverageSTATE 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.DB-802 (10-17) Other: Initial Supersedes Reinstatement Termination Transaction Effective Date: 2. EMPLOYER STREET ADDRESS 5. NUMBER (#) OF EMPLOYEES A. CURRENT EMPLOYER INFORMATION 7. WCB PLAN NUMBER 8. EFFECTIVE DATE OF COVERAGE B. PLAN INFORMATION Non-Payment of Premium Not Subject/No Eligible Employees Seasonal Out of Business Date: Date: Date: DATE CANCELLATION OR TERMINATION SENT TO EMPLOYER: D. Complete if TERMINATION box is checked at top of form (attach DB-118 if employer is terminating status as covered employer) 1. EMPLOYER'S LEGAL NAME, INCLUDING (DBA/AKA/TA) 4. EMPLOYER FEIN Reason(s) for modification: 3. EMPLOYER CITY, STATE and ZIP CODE 6. TELEPHONE NUMBER 10. NAME OF ASSOCATION, UNION OR TRUSTEES PLAN 12. INSURANCE POLICY NUMBER (If applicable) 11. NAME AND CARRIER IDENTIFICATION NUMBER (If Plan coverage through carrier) E. Complete if SUPERSEDES box is checked at top of form Self-Insurance Insurance Carrier C. COVERAGE Both disability and paid family leave benefits Disability benefits only Paid family leave benefits onlya.The policy provides coverage for: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: 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 Telephone Number Name and Title BySignature of Association, Union or Trustee OfficialSECTIONS 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. American LegalNet, Inc. www.FormsWorkFlow.com DB-802 (10-17) REVERSEG. INITIAL CERTIFICATION BY EMPLOYER Date Signed Name and Title Telephone Number By Employer being duly sworn, deposes and says: A. The EMPLOYER requests acceptance of this PLAN identified by WCB Plan Number ofState of New YorkCounty of Association, Union or Trusteesas the EMPLOYER'S Plan.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. day of Signature of Notary PublicSworn to before me thisSignature of Owner, Partner or Authorized Officer 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 13902-5200THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION