Fill and Sign the New York Claim Benefits Form

                                                                                                                                     9. Description (Diagnosis) of injury       10. Place where injury occurred (city/county/state)                                     CLAIM IS NOT DISPUTED. PAYMENT HAS BEGUN. TEMPORARY PAYMENT HAS BEGUN WITHOUT PREJUDICE AND WITHOUT ADMITTING LIABILITY (Sec. 21-a WCL) at a weekly rate of $       Check here if weekly rate shown is a temporary rate subject to adjustment upon receipt of payroll information and complete section 2 below. Average Daily Wage $                   $       x 2/3 = Weekly Comp. Rate (Subject to Maximum) If temporary rate indicate basis       CLAIM IS NOT DISPUTED. PAYMENT HAS NOT BEGUN FOR FOLLOWING REASON(S): No lost time beyond 7 days. (In volunteer firefighters' and ambulance workers' cases, 7 day waiting period does not apply.) Employer requests reimbursement in the amount of $       Death case awaiting information as to dependents, if any, or dependency proofs - accidental death not controverted.       Name       Telephone No.       Prepared by       Official Title            / / - - / / / / / / / / / / / / CHECK TYPE OF CASE: WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER ANSWER ALL QUESTIONS FULLY - TYPEWRITER OR COMPUTER PREPARATION IS REQUIRED ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS1. WCB Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. Social Security Number Nam e Address to which notices should be sent 6. Injured Person 7. Employer* 8. Carrier *In volunteer firefighters' and volunteer ambulance workers' cases, enter the liable political subdivision (or unaffiliated ambulance service as defined in VAWBL) as the EMPLOYER 11. Date disability began 12. Date employer or carrier first had knowledge of injury, whichever is earlier 13. Date of receipt by carrier of employer's report of injury (C-2, VF-2 or VAW-2) (If none, so state) 14. Date returned to work (if applicable) 15. A. Complete Items 1 and 2 below if either 15-A or 15-B is checked. B. 1. Payment has begun from Date first payment mailed If the rate is less than the maximum in effect on the date of the injury (WCL 15, subd. 6(a)), the, basis for the computation MUST be entered in item 2 and supporting documents (payroll or other) MUST be attached.2. Basis For Computation - Workers' Compensation Cases Only x = $ 52 = Average Weekly Wage Check here if payment made without prejudice, as provided in Sec.50 VFBL/VAWBL, pending determination of political subdivision/vol. ambulance service liable for benefits Death Cases : attach list of payees, showing name and address, relationship to deceased, date of birth, percentage of award and rate per week for each payee, if known. Also include name and address of undertaker, amount of funeral bill, amount of funeral bill paid and by whom (name and address). 16. a. b. Lost time exceeds 7 days, no medical evidence indicating disability beyond 7 days. (When such evidence is available, carrier must commence payment.) c. Possible schedule loss or disfigurement, but no loss of time from work at regular wages beyond 7 days. d. Lost time exceeds 7 days, but full wages being paid by employer during disability. for the period to e. f. Other 17. Designated carrier employee (see NYCRR 325-1.4) who receives requests for authorization of special medical services costing more than $500. The insurance company will notify the Chair, Workers' Compensation Board, and the claimant and his/her representative, if any, if benefits are stoppedor modified, or of any other change in the above information. Dated ... Telephone No. & Extension Prescribed by Chair C-669 (4-06) Workers' Compensation Board SEE IMPORTANT INFORMATION TO CLAIMANT AND CARRIER ON REVERSE. State of New York This notice must be filed with the CHAIR, Workers' Compensation Board, by the Insurance Company or Self-Insured Employer at the office of the district in which the injury occurred. IF PAYMENT (INCLUDING TEMPORARY PAYMENT WITHOUT PREJUDICE) HAS BEGUN, this form must be filed on or before the 18th day after disability, or within 10 days after the employer first had knowledge of the injury whichever period is greater. IF PAYMENT HAS NOT BEGUN, this form must be filed no later than 25 days after the Board has mailed the notice of indexing of a case. A copy of this notice must also be mailed to the CLAIMANT, to his or her REPRESENTATIVE if any, at the same time it is filed with the Chair. TO THE CLAIMANT This notice shows that your employer or its insurance company has either: a. If Item 15-A if checked -- started to pay benefits to you without waiting for an award by the Workers' Compensation Board. or b. If Item 15-B is checked - started to pay temporary benefits to you without admitting liability for your claim. or c. If Item 16 is checked - does not now dispute the injury described on the other side of this form, but has not begun to pay benefits for the reasons shown. IF PAYMENT HAS BEGUN (Item 15-A), payment of benefits will be made to you, generally every two weeks, at the rate shown on the other side of this notice. Payments will continue until your employer or its insurance company notifies you and the Board, on Form C-8/8.6, that such payments are being stopped or modified for reasons which will be stated on the form. The Board will then notify you in writing of any further action taken in your claim.In order to avoid delays in payment, the insurance carrier may sometimes use a temporary compensation rate until payroll information is obtained from the employer. Later, when the proper rate is established, prior payments may have to be adjusted. The weekly rate at which payments are made is always reviewed by the Board. IF TEMPORARY PAYMENT HAS BEGUN (Item 15-B), payments may continue for up to one year or until your employer or its insurance company notifies you and the Board, on Form C-8/8.6, that such payments are being stopped. The Board will then notify you in writing of any further action taken in your claim. This payment is not an admission of liability by the employer for your injury or injuries. You may be required to enter into an agreement with the employer to ensure continuation of payment of temporary compensation. IF PAYMENT HAS NOT BEGUN (Item 16), the reason(s) for non-payment will be indicated on the front of this notice. The Board will review your claim to determine if any benefits are payable to you. The Board may schedule a hearing or meeting to resolve outstanding issues. Permanent defects or disfigurements are usually evaluated six months to one year after an injury and may require your appearance at the Board. You are entitled to compensation if your injury keeps you from work more than one week (with loss of wages); forces you to work at lower wage; or leaves you with permanently injured eyesight or hearing, serious facial scars, or any permanent defect in a finger, hand, toe, foot, leg or arm. In volunteer firefighters' and volunteer ambulance workers' cases, you are entitled to benefits if your injury keeps you from work for even one day. Do not pay any doctor or hospital bills in connection with your injury. All medical bills should be sent to your employer or its insurance company. If you, or your private health insurer, have spent money for medicine, drugs, transportation or medical bills relating to your injury, you are entitled to reimbursement. Send bills or receipts for these expenses to your employer or its insurance carrier. If you are not reimbursed, advise the Board. The Law permits the employer or its insurance company to have its doctors examine you periodically at a reasonably convenient place. You may be asked to submit to such an examination from time to time. You are allowed to have your own doctor present at these examinations if you wish. If you refuse to be examined, your benefits may be stopped or reduced. VOLUNTEER AMBULANCE WORKERS AND VOLUNTEER FIREFIGHTERS In volunteer ambulance workers, and volunteer firefighters' benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in the Volunteer Ambulance Workers' Benefit Law) is considered the "employer," with respect to the information given above. BE SURE TO NOTIFY THE WORKERS' COMPENSATION BOARD AND THE INSURANCE COMPANY OF ANY CHANGE IN YOUR ADDRESS IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE OR YOUR CASE OR WITH RESPECT TO YOUR RIGHTS UNDER THE WORKERS'COMPENSATION LAW OR THE VOLUNTEER FIREFIGHTERS' VOLUNTEER AMBULANCE WORKERS' OR DISABILITY BENEFITS LAWS YOUSHOULD CONSULT THE NEAREST OFFICE OF THE BOARD FOR ADVICE. ALWAYS USE THE CASE NUMBERS SHOWN ON THE OTHER SIDE OF THIS NOTICE, OR ON OTHER PAPERS RECEIVED BY YOU, IF YOU FIND IT NECESSARY TO WRITE OR CALL THE BOARD. TO THE CARRIER: Section 114 of the Workers' Compensation Law provides, in part, that any employer or carrier, or any employee, agent, orperson acting on behalf of an employer or carrier, who knowingly makes a false statement or representation as to material fact for the purposeof avoiding provision of any payment or benefit under this chapter shall be guilty of a felony. 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(866)805-3630 HAUP(866)681-5354 PEEK(866)746-0552 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-669 (4-06) Reverse www.wcb.state.ny.us