STATE OF NEW YORK THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. WORKERS' COMPENSATION BOARD ______________________________________ WCB Plan No. (Enter number assigned to Association, Union or Trustees Plan) DISABILITY BENEFITS LAW NOTICE OF TERMINATION OF EMPLOYER'S PARTICIPATION IN SELF-INSURED ASSOCIATION, UNION OR TRUSTEES PLAN Complete two copies of this form. File original with the Chair, Workers' Compensation Board, and mail a copy to the employer. NAME OF ASSOCIATION, UNION OR TRUSTEES hereby gives notice that EMPLOYER'S participation in the Disability Benefit Plan identified above is to be terminated, as indicated herein: A. EMPLOYER'S NAME AND ADDRESS B. EMPLOYER'S U.I. REGISTRATION NO. C. APPROXIMATE NUMBER OF EMPLOYEES COVERED E. PAYROLL RECORDS ADDRESS, IF DIFFERENT D. NAME UNDER WHICH EMPLOYER CONDUCTS BUSINESS MONTH, DAY, YEAR MONTH, DAY, YEAR 1. Date that EMPLOYER'S participation in the Plan identified above is to be terminated..................... 2. Date that a copy of this Notice of Termination was sent to the EMPLOYER................................. 3. Reason for termination of EMPLOYER'S participation:* _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Date signed___________________________________________ ______________________________________________ NAME OF ASSOCIATION, UNION OR TRUSTEES Tel. Number__________________________________________ ______________________________________________ SIGNATURE OF AUTHORIZED OFFICIAL ______________________________________________ TITLE *1. If Reason for Termination is "EMPLOYER out-of-business" give date and supplementary information such as: "seasonal closing", "liquidation", "removed from state", etc. 2. If Reason for Termination is "EMPLOYER no-longer-subject" (to the NY Disability Benefits Law) - attach completed set of Form DB-118, Employer's Statement for the Purpose of Terminating Status as a Covered Employer, or give date on which previous Form DB-118 filed for the EMPLOYER was approved. 3. If "change-in-ownership" enter name, address and employer registration number of successor and, if successor-employer is to participate in the Plan, attach completed Form DB-802 for successor-employer. MAIL ORIGINAL TO : DISABILITY BENEFITS BUREAU PLANS ACCEPTANCE UNIT 100 BROADWAY-MENANDS ALBANY, NY 12241-0005 DB-159.1 (2-03) MAIL A COPY TO EMPLOYER American LegalNet, Inc. www.USCourtForms.com