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CLAIM for VOLUNTEER FIREFIGHTERS' BENEFITS in a DEATH CASE Wcb Ny  Form

CLAIM for VOLUNTEER FIREFIGHTERS' BENEFITS in a DEATH CASE Wcb Ny Form

Use a CLAIM FOR VOLUNTEER FIREFIGHTERS' BENEFITS IN A DEATH CASE Wcb Ny template to make your document workflow more streamlined.

Or b. Death certificate. malfunction of the heart or of one or more c. Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc. coronary arteries? d. Itemized funeral bill. Yes No W.C.B. CASE NO. (if known) CARRIER CASE NO. CARRIER CODE NO. DECEDENT'S SOC. SEC. NO. CLAIMANT'S SOC. SEC. NO. NAME DATE OF ACCIDENT ADDRESS (Give No, Street,City, State and Zip Code) Apt. No. DECEASED VOLUNTEER FIREFIGHTER FIRE COMPANY POLITICAL SUBDIVISION LIABLE FOR...
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