TAKE NOTICE that under the provisions of Section 212, Subdivision 5 of the NYS Disability and Paid Family Leave Benefits Law, the employer named below elects to exclude his or her spouse named below from coverage under the NYS Disability and Paid Family Leave Benefits Law. If the employer provides disability and paid family leave benefits to his or her employees through an insurance policy, such exclusion will be applicable with respect to all policies issued to the employer by the above-named insurance carrier as long as it shall continuously insure the employer.DB-212.5 (10-17) Prescribed by the Chair Workers' Compensation Board New York StateSTATE OF NEW YORK WORKERS' COMPENSATION BOARD NOTICE OF ELECTION TO VOLUNTARILY EXCLUDE SPOUSE FROM COVERAGE PURSUANT TO SECTION 212, SUBDVISION 5 OF THE NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW TO (print name and address of insurance carrier here): Name of Employer: Mailing Address: Name of Spouse Excluded from Policy:THIS ELECTION IS FINAL AND BINDING UPON THE SPOUSE NAMED IN THIS NOTICE UNTIL REVOKED BY THE EMPLOYER. See reverse side for instruction on how to revoke this election and for a copy of relevant portion of Section 212, Subdivision 5 of the Disability and Paid Family Leave Benefits Law. By: Telephone Number: Date: INSTRUCTIONS: Sole-proprietorships, regular partnerships, individual trustees, individual receivers and legal representatives may be eligible for spousal exemptions. Corporations, LLCs, LLPs, LPs, PLLCs, PLLPs, RLLCs, RLLPs, Joint Ventures, associations, unions, and non-profits are NOT eligible for spousal exemptions. 1. If the employer has other employees and disability and paid family leave coverage through an insurance policy, complete and file this form with the insurance carrier. 2. If the employer has no other employees or is an approved self-insurer, complete and file this form with the Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200. Social Security No. of Spouse: DB-212.5 10-17PO BOX 5200, Binghamton, NY 13902-5200www.wcb.ny.gov THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATIONREVACTION OF ELECTION TO VOLUNTARILY EXCLUDE SPOUSE FROM COVERAGE PURSUANT TO SECTION 212, SUBDIVIDION 5 OF THE NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW INSTRUCTIONS: To revoke the election to exclude a spouse from coverage under the NYS Disability and Paid Family Leave Benefits Law, complete the section below and: 1. If the employer has other employees and has disability and paid family leave coverage through an insurance policy, complete and file this form (DB-212.5 Reverse) with the insurance carrier. 2. If the employer has not other employees or is an approved self-insurer, complete and file this form (DB-212.5 Reverse) with the Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200. TO (print name and address of insurance carrier here): TAKE NOTICE that the employer named below revokes the election to exclude his or her spouse from coverage under the New York State Disability and Paid Family Leave Benefits Law. The employer wishes to include his or her spouse in the coverage under the NYS Disability and Pail Family Leave Benefits Law, and the previously filed election to exclude the spouse (DB-212.5) is REVOKED.Section 212, Subdivision 5 of the New York State Disability and Paid Family Leave Benefits Law A spouse who is an employee of a covered employer shall be deemed to be included in the employer's disability benefits insurance contract or covered by a certificate of self-insurance or a plan under section two hundred eleven of this article, unless the employer elects to exclude such spouse from the coverage of this article. Such election shall be made by any such employer filing with the insurance carrier, or the chair of the workers' compensation board in the case of self-insurance, upon a form prescribed by the chair, a notice that the employer elects to exclude such spouse named in the notice from the coverage of this article. Such election shall be effective with respect to all policies issued to such employer by such insurance carrier as long as it shall continuously insure the employer. Such election shall be final and binding upon the spouse named in the notice until revoked by the employer. Name of Employer: Mailing Address: Name of Spouse INCLUDED from Policy:DB-212.5 (10-17) Reverse Prescribed by the Chair Workers' Compensation Board New York State Social Security No. of Spouse: By: Telephone Number: Date:PO BOX 5200, Binghamton, NY 13902-5200www.wcb.ny.gov THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION DB-212.5 10-17