STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. NOTICE OF ELECTION TO PROVIDE WORKERS' COMPENSATION BENEFITS TO PARTICIPANTS IN A SHELTERED WORKSHOP To: Chairman, Workers' Compensation Board To: (Print name and address of insurance carrier here) TAKE NOTICE, that under the provisions of Section 33.09 of the Mental Hygiene Law, as amended by Chapter 690 of the Laws of 1989, the office or agency named hereby elects to provide workers' compensation benefits (excluding benefits provided under Article Nine of the Workers' Compensation Law) to the participants in the sheltered workshop programs named below, with respect to all policies issued to the office or agency by the insurance carrier named above. Name of Office or Agency.................................................................................................................................................................. Address............................................................................................................................................................................................. SHELTERED WORKSHOP PROGRAMS TO BE INCLUDED IN POLICY Name Address No. of Participants I,................................................................................of the herein named office or agency certify that the above election to include (Name of authorized person) (Title) participants in sheltered workshop programs described above was duly made at a meeting of the Board or other executive body duly authorized by Law to take such action, and that copies of this notice have been filed this day with the Chairman, Workers' Compensation Board and the insurance carrier named above. Name of Office or Agency................................................................................................................................................................ By....................................................................................... Tel. No:.............................................. Date......................................... (Signature) Section 33.09, Subdivision (c) of the Mental Hygiene Law "(c) The provisions of the workers' compensation law, the unemployment insurance law, and articles thirteen, nineteen, and twenty of the labor law shall not apply to any patient in a facility with respect to his/her participation in a sheltered workshop program, however, that participants in sheltered workshop programs operated by the office of mental health, the office of mental retardation and developmental disabilities or voluntary agencies or institutional worker programs operated by the office of mental health shall be eligible for workers' compensation benefits (excluding benefits provided pursuant to article nine of the workers' compensation law) if such offices or agencies elect to provide such benefits. Sheltered workshops operated at department facilities shall be subject to the laws and regulations applicable to sheltered workshops operated by voluntary agencies." C-105.54 (3-99) 2001 © American LegalNet, Inc.