STATE OF NEW YORK WORKERS’ COMPENSATION BOARD …
WORKERS’ COMPENSATION BOARD CERTIFICATE OF NYS WORKERS’ COMPENSATION INSURANCE COVERAGE 1a. Legal Name & Address of Insured (Use street address only) Vendor name and address 1c. Work Location of Insured (Only required if 1d.coverage is specifically limited to certain locations in orNew York State, i.e., a Wrap-Up Policy) 1b. ................
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