Fill and Sign the A Guide to the New York State Volunteer Firefighter Benefits Form

State of New York WORKERS' COMPENSATION BOARD VF/VAW ADJUSTMENTS CARRIER'S REQUEST FOR BENEFIT INCREASE REIMBURSEMENT UNDER SECTION 51 VOLUNTEER FIREFIGHTERS' & VOLUNTEER AMBULANCE WORKERS' BENEFIT LAWS WCB Case No. Carrier Case No. Claimant Social Sec. No. Carrier: \ Vol. Fire Claim Vol. Ambulance Claim Carrier Address: Original weekly benefit rate in this claim: $_________ Increased bene\ fit rate effective Jan. 2, 2006: $_________ The Carrier requests reimbursement for benefits paid, as follows: A. Compensation/Death Benefits Weeks from To at $ /wk $ B.Lump Sum ............................................\ .................................................................... $ C. Re-marriage Award .................................................\ ............................................................... $ TOTAL OF THIS CLAIM FOR REIMBURSEMENT $ 1. Does this represent an initial request for reimbursement in this claim? \ Yes No 2. If this is the initial request for reimbursement, or re-marriage award, \ you must attach the following: a. A copy of the Notice of Decision establishing the classification and ben\ efit rate or award. b. A copy of Form C-8/8.6 verifying the rate change. CARRIER STATEMENT I hereby certify that this request for reimbursement made to the Chair of the Workers' Compensation Board is true and correct;that no part thereof has been previously paid and that the amount stated\ therein is due and owing. By (Print or Type): Telephone No. Signature: Title: Date: INSTRUCTIONS: 1. Claims for compensation reimbursement should be submitted for 52-week\ periods. 2. Forward original and one copy, along with any required documentation \ to: WORKERS' COMPENSATION BOARD FUND FOR REOPENED CASES UNIT 328 STATE STREET, SCHENECTADY, NY 12305 3. Retain one copy for your records. VF/VAW-10 (10-06) Original weekly benefit rate in this claim: $_________ Increased benef\ it rate effective July 27, 2004: $_________ (VAW ONLY) Weeks from To at $ /wk $ Weeks from To at $ /wk $ Original weekly benefit rate in this claim: $_________ Increased bene\ fit rate effective Jan. 1, 1999: $_________ www.wcb.ny.gov