Fill and Sign the Carrier ID No Form

STATE OF NEW YORK WORKERS' COMPENSATION BOARD CARRIER'S REQUEST FOR REIMBURSEMENT OF MEDICAL EXPENSES UNDER SEC. 15-8 I hereby certify that this request for reimbursement made to the Chairman of the Workers' Compensation Board is true and correct; that no part thereof has been previously paid and the amount stated therein is due and owing. Signature:_____________________________________________________ Date:______________________________ Title:______________________________________________ Telephone No.:_____________________________ INSTRUCTIONS: 1. Where possible, claim should be submitted for 26 week periods. 2. Forward original and two copies to the local office of the Special Funds Conservation Committee. 3. Retain one copy. In support of this request the following statements are submitted: MEDICAL EXPENSES: Paid for treatment rendered during period from______________________________ To_______________________. (Receipted bills or photocopies must be attached to original copy.) \ TOTAL $_____________________ C-251.1 (11-01) DO NOT USE SPACE BELOW TO: CHAIRMAN, WORKERS' COMPENSATION BOARD The Special Funds Conservation Committee approves reimbursement for the above claim totaling $_____________________. Agreed Date for Medical Reimbursement_________________________________ By_______________________________ Date__________________________ S T A T E M E N T www.wcb.ny.gov WCB CASE NO. CARRIER CASE NO. CARRIER ID NO. W SOC. SEC. NO. CLAIMANT'S NAME CARRIER'S ADDRESSCARRIER'S NAME