Fill and Sign the 497321606 Form

                                                                                            / / - -NOTICE OF RIGHT TO REIMBURSEMENT OF COMPENSATION PAYMENTS UNDER SECTION 14 (6) AND SECTION 15 (8) W.C.B. CASE NO. CARRIER CASE NO. CARRIER CODE DATE OF ACCIDENT CLAIMANT CLAIMANT's SOC. SEC. NO. EMPLOYER CONCURRENT EMPLOYER CONCURRENT EMPLOYER's ADDRESS The claimant herein claims to have been concurrently engaged in more than one covered employment at the time of injury. As a representative of the employer in whose employment the claimant was injured we assert our right to file this Notice of Right to Reimbursement of Compensation Payments in accordance with Section 14 (6) and Section 15 (8) of the Workers' Compensation Law. Prepared By Date Title Tel. No. INSTRUCTIONS: Prepare this form in triplicate (three copies) and file as follows: 1. Original to the Claims Section in the office of the Workers' Compensation Board where the case is pending (see District Office addresses below). Notice must be filed prior to the decision making an award or your right to reimbursement may be deemed waived. 2. Forward one copy to Workers' Compensation Board, 20 Park Street, Albany, New York 12207, ATT: FINANCE OFFICE. 3. Retain one copy for your files. WORKERS' COMPENSATION BOARD DISTRICT OFFICES DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC(800)877-1373 HEMP(516)560-7700 HAUP(631)952-6000 PEEK(914)788-5775 100 Broadway State Office Building Statler TowersMenands 44 Hawley Street 107 Delaware Ave. ALBANY 12241 935 James Street BINGHAMTON 13901 BUFFALO 14202 ROCHESTER 14614 (866) 750-5157 (866) 211-0645 (866) 211-0644 SYRACUSE 13203 (866) 802-3604 (866) 802-3730 C-251.3 (8-06) www.wcb,stete,ny,us