Notice Of Termination Of Employers Participation In Self-Insured Association Union Or Trustees Plan
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Notice Of Termination Of Employers Participation In Self-Insured Association Union Or Trustees Plan Form. This is a New York form and can be use in Workers Compensation.
Tags: Notice Of Termination Of Employers Participation In Self-Insured Association Union Or Trustees Plan, DB-159.1, New York Workers Compensation,
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
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