Fill and Sign the Carriers Request for Reimbursement of Compensation Form

www.wcb.Q\JRY STATE OF NEW YORK WORKERS' COMPENSATION BOARD CARRIER'S REQUEST FOR REIMBURSEMENT OF COMPENSATION PAYMENTS UNDER SEC. 15-8 The Carrier requests reimbursement for benefits paid, as follows: A. _________ weeks from ________________ to ________________ at $ _________________ $ ________________ __________ weeks from ________________ to ________________ at $ _________________ $ ________________ __________ weeks from ________________ to ________________ at $ __________________$ _______________ B. Lump sum payment representing _____________ weeks at $ __________________per week. $ ________________ C. Funeral Expenses________________________________________________________________\ $ _____________ D. Other (Specify) __________________________________________________________________ $ ___\ __________ \ TOTAL CLAIM FOR REIMBURSEMENT $ C-251 (11-01) 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. The summary below is to be used for all initial claims. If desired, Form C-8/8.6 may be substituted and attached to the original copy. The summary (or Form C-8/8.6) must include all payments from date of accident through the period for which reimbursement is requested. S T A T E M E N T 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 the amount stated therein is due and owing. Signature:_________________________________________________________ Date: ____________________________ Title:__________________________________________________ Telephone No.:____________________________ 1. Does this claim represent an initial request for reimbursement of compensation payments ? Yes No 2. Date Claimant's status was last checked_______________________ 3. Is there a third party action on this claim? Yes No If yes, is this action pending dismissed settled SUMMARY OF COMPENSATION PAYMENTS Period(s) of Payments From To Less Days Worked Number of Weeks Weekly RateWCB CASE NO. CARRIER CASE NO. CARRIER ID NO. W SOC. SEC. NO. CLAIMANT'S NAME CARRIER'S ADDRESSCARRIER'S NAME TO: CHAIR, WORKERS' COMPENSATION BOARD DO NOT USE SPACE BELOW The Special Funds Conservation Committee approves reimbursement for the above claim totaling $_____________________. Agreed Date for Compensation Reimbursement___________________________ By_______________________________ Date__________________________