This supplement is attached to and made a part of the Certificate of Insurance, Form DB-820/829, filed for: by and said carrier certifies that benefits are payable to eligible employees at least to the extent described herein. Name of Employer Name of CarrierSTATE OF NEW YORK WORKERS' COMPENSATION BOARD DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW SUPPLEMENT TO CERTIFICATE OF INSURANCE Employer FEIN WCB Plan # CLASS OR CLASSES OF EMPLOYEES BENEFIT AMOUNT OR RATE EMPLOYEE CONTRIBUTION (Weekly) ELIGIBILITY REQUIREMENT MAXIMUM DURATION (Weeks) WAITING PERIOD (Days) Please fill out for Schedule of Disability Benefits and Contributions. Paid Family Leave Benefits Schedule is found on Form PFL-820.1. Benefits must be at least as favorable as the requirements of Article 9 of the Workers' Compensation Law, including the definition of disability. Are there any other benefits, differences or restrictions that are different than those specified in the Disability and Paid Family Leave Benefits Law? If "Yes", list below. Yes NoTHE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATIONDB-820.1 (3-18)BENEFIT AMOUNT OR RATE: The benefit amount must be at least 1/2 of the employee's average weekly wage, until the benefit amount is at least 170 dollars a week. An employee making less than 20 dollars per week must receive at least his or her average weekly wage (WCL Section 204). MAXIMUM DURATION OF BENEFIT (IN WEEKS): The duration of disability benefits must be at least 26 weeks within a 52 consecutive calendar week period or for any one period of disability, less any days taken for paid family leave (WCL Section 205). WAITING PERIOD (DAYS): Under Section 204 of the WCL, the waiting period cannot be longer than 7 days of disability. ELIGIBILITY REQUIREMENT: Employees working a normal work week must become eligible after 4 weeks of work; those working less than the employer's normal work week must become eligible with 25 days (WCL Section 203). EMPLOYEE CONTRIBUTION PER WEEK: If the total amount of employee contributions entered above is in excess of one-half of 1% of wages paid or more than $.60 per week, such contributions must be entered into by agreement and reasonably related to the value of the benefits as determined by the Chair under Section 211 of the WCL.ATTACH ADDITIONAL SHEETS, IF NECESSARY. American LegalNet, Inc. www.FormsWorkFlow.com