Fill and Sign the New York Compensation Form

                                                                                                                            12. Place where alleged injury occurred                                                       Name                         Official Title       / / - - / / CHECK TYPE OF CASE: WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER ANSWER ALL QUESTIONS FULLY ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. Social Security Number Name Address to which notices should be sent (Give Number and Street, City, State, and Zip Code) Apt. No. 6. Injured Person 7. Employer* 8. Carrier 9. Volunteer Fire or Ambulance Company, if applicable 10. Claimant's Doctor • In volunteer firefighters' and volunteer ambulance workers' benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in Sec. 30 VAWBL)is deemed to be the "EMPLOYER''. 11. Description (Diagnosis) of Alleged Injury (City, Town or Village) (County) (State) 13. Right to compensation is controverted for the following reasons: State reasons fully and explicitly. Attach supporting medical reports if reasons include contention that disability is not causally related.EACH BASIS FOR CONTROVERSY MAY BE CONSIDERED FRIVOLOUS AND SUBJECT TO A PENALTY UNLESS SUPPORTING DOCUMENTATION IS ATTACHED. 14. Date alleged disability began 15. Date employer or carrier first had knowledge of alleged injury, whichever is earlier 16. Date of receipt by carrier of employer's report of injury (C-2, VF-2 or VAW-2) (If None, So State) 17. Is the alleged injury the result of the use or operation of a motor vehicle? YE S NO If yes, provide name and address of NO-Fault carrier 18. 12 NYCRR 363.12 requires that an employer or carrier controverting a claim for benefits promptly furnish a copy of Form C-7 and medical report(s), if any, to the disability benefits carrier or self-insured employer.A. Has a copy of this notice been sent to the DISABILITY BENEFITS CARRIER or SELF-INSURED EMPLOYER?: YE S Enter name and address to whom sent, in the space provided below, and answer "B" below. NO Indicate below, reasons for failure to comply with 12 NYCRR 363.12. If unable to determine disability benefits carrier, sendcopy of form C-7 with medical report(s), if any, to the employer and advise employer to transmit to its DB carrier. (InVF/VAW cases, send to Regular Employer , if any, and enter name and address below.) (Name and address of DB carrier or Employer- Please endeavor to identify the DB carrier in every instance) B. Have you also sent copies of medical reports in your possession to the DB Carrier or Employer? YE S NO 19. Designated carrier employee (see NYCRR 325-1.4 ) who receives requests for authorization of special medical services costing more than $500. Tel. No. & Ext. Dated Prepared By Tel. No. & Ext. Prescribed by Chair C-7 (4-06) Workers' Compensation Board SEE REVERSE SIDE State of New York THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. I In workers' compensation cases, this notice must be filed by the Insurance Company or Self-insured Employer with the CHAIR, Workers' Compensation Board, at the office of the district in which the alleged injury occurred, on or before the 18th day after disability or within 10 days after the employer first had knowledge of the alleged injury, whichever period is greater. A copy of this notice mus t also be mailed to the CLAIMANT, to his or her REPRESENTATIVE, if any, and to ALL HEALTH PROVIDERS treating the claimant simultaneously with its filing with the Chair. In lieu of a copy of this notice, the carrier may send ALL HEALTH PROVIDERS a written explanation stating that legal objections have been raised. As required by 12 NYCRR 363.12 a copy of this notice with medical report(s), if any, must also be furnished promptly to the DISABILITY BENEFITS CARRIER. TO THE CLAIMANT 1. This notice indicates that your employer or the liable political subdivision in volunteer firefighters' or volunteer ambulance workers' cases (if self-insured), or its insurance company, or an unaffiliated volunteer ambulance service, if covered under the VAWBL, or itsinsurance company, is disputing your entitlement to benefits in connection with the injury described on the other side of this notice,for the reasons stated. 2. The Workers' Compensation Board will schedule your case for a hearing before a W.C. Law Judge as quickly as possible, so that the issues raised by your employer (the liable political subdivision or an unaffiliated volunteer ambulance service or its insurancecompany) may be considered and a decision reached on your right to such benefits. 3. ATTEND THE HEARING WHEN YOU ARE NOTIFIED TO APPEAR. You have the right to be represented by an attorney or a duly licensed claimant's representative at such hearings if you wish. You are not, however, to pay for their services directly. Their feewill be fixed by a W.C. Law Judge and deducted from your award if one is made. 4. If you have not already done so, you should file a Claim for Compensation (Form C-3, VF-3 or VAW-3) with the Board to protect your rights. In volunteer firefighters' and volunteer ambulance workers' cases, a copy of such claim should also be filed with thedesignated officer of the liable political subdivision or unaffiliated volunteer ambulance service. Detailed instructions for filing arecontained on the claim forms, which may be obtained by writing to or calling at any office of the Board. 5. Pending determination of your right to workers' compensation or volunteer firefighters' or volunteer ambulance workers' benefits, you may be entitled to receive certain benefits under the provisions of the Disability Benefits Law, provided that your claim is beingdisputed on the grounds that your disability is not the result of an on-the-job injury or illness or the result of a line-of-duty injury (involunteer firefighters' or volunteer ambulance workers' cases), you are eligible for disability benefit payments, and provided furtherthat a medical report indicating that you are disabled has been properly filed by your doctor with the insurance carrier named inItem 8 on the other side of this notice. If these benefits are payable, payments will be made directly by the disability benefitscarrier, but such payments will be deducted from any award of workers' compensation, volunteer firefighters' or volunteerambulance workers' benefits ultimately made. If within 45 days you do not receive disability benefits or do not receive a Notice ofRejection (Form DB-451), promptly contact any office of the Workers' Compensation Board. (See addresses and telephonenumbers below.) 6. Your doctor's bills (and bills for hospital and other services of a medical nature) will be paid by your employer (the liable political subdivision or the unaffiliated volunteer ambulance service or its insurance company) if your claim is allowed. Do not pay thesebills yourself pending a determination of the compensability of the claim. IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE OR YOUR CASE, OR WITH RESPECT TO YOUR RIGHTS UNDER THE WORKERS' COMPENSATION LAW, ORTHE VOLUNTEER FIREFIGHTERS', VOLUNTEER AMBULANCE WORKERS' OR DISABILITY BENEFITS LAWS, YOU SHOULD CONSULT THE NEAREST OFFICE OF THEBOARD 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 HEALTH PROVIDER The liability for this workers' compensation claim has not yet been determined. You will receive a Notice of Decision advising of theoutcome. If the Board decides that the Insurance Carrier or Self-Insured Employer is responsible for this claim, you will receivepayment and/or a written explanation from the carrier or self-insured employer as to its reasons for non-payment. Should the Boarddisallow this claim, the patient may be responsible for payment of medical expenses. If your bill has been disputed and if the decisionis in your favor and the employer or carrier does not pay the amount awarded or provide a written explanation objecting to valuerelated issue(s), within 30 days from the date of decision, you are entitled to file an HP-1 form applying for an administrative award.Should the carrier provide a written explanation within the 30 day period raising issue(s) of value of medical aid rendered, you areentitled to file for arbitration on Form HP-1, if communication does not resolve the issue(s). FILING FOR AN ADMINISTRATIVE ORARBITRATION AWARD (FORM HP-1) PRIOR TO THE RESOLUTION OF THE ISSUE(S) INDICATED ON THE FRONT OF THIS FORM ISPROHIBITED. TO THE CARRIER OR SELF-INSURED EMPLOYER Section 114 of the Workers' Compensation Law provides, in part, that any employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who knowingly makes a false statement or representation as to material fact for the purpose of 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-7 (4-06) Reverse www.wcb.state.ny.us