Fill and Sign the New York Compensation Ny Form

DISFIGUREMENT      LUMP SUM PAYMENT (Include Lump Sum Non-Schedule Adjustment or Lump Sum Advance on a Schedule Loss Award)       Yes No      WORKERS’ COMPENSATION                                                                                                 14. Description (Diagnosis) of injury                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Claimant returned to work. Date of return: There is a change in condition and/or earnings. (A medical report or other supporting documentation must be attached.)Payments stopped or modified for other reason. (Explain below and/or attach explanation/documentation.)       At pre-injury wages At reduced wages       NOTICE OF TERMINATION OF TEMPORARY PAYMENTS OF COMPENSATION (Sec. 21-a WCL) Employer or carrier is ceasing payment of temporary compensation. See special information box on reverse. Last payment was made on             Prepared by       Official Title             Telephone, No. & Extension             NOTICE THAT PAYMENT OF COMPENSATION HAS BEEN STOPPED OR MODIFIED VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. WCB 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 6. Claimant/Name of Deceased 7. Employer* 8. Carrier * In VF and VAW benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in Sec. 30 VAWBL is deemed to be the "EMPLOYER". 9. County Where Injury Occurred 10. Date Disability Began or Date of Death 11. Average Weekly Wage 12. Date First Payment Mailed 13. Date Most Recent Payment Mailed $ 15. SUMMARY OF BENEFIT PAYMENTS Indicate Type of Disability Period(s) of Payment Less Days Worked Number of Weeks Weekly Rate Amount TOTAL/PARTIAL PERM./TEMP. From TO From TO Paid To Or For DEATH BENEFITS Lump Sum Death Benefit (VFBL and VAWBL only) Funeral Expenses State Treasurer (Sections 15-9, 25-a or 26-a) Payment made into Aggregate Trust Fund - Date: TOTAL AWARD PENALTY PAYMENT TO CLAIMANT LESS : a. Fees to representative: $ b. Reimbursement to - $ c. Other (specify): $ TOTAL DEDUCTIONS (a+b+c) $ BALANCE TO CLAIMANT 16. Have benefits been paid in full in accordance with an award of the WCB? If "No," check and complete items a-c, as appropriate: a. b. C. 17. Reason for termination of payments: Dated 8/8.6 C-8/8.6 (7-99) Prescribed by ChairWorkers' Compensation BoardState of Now York SEE IMPORTANT INFORMATION TO CLAIMANT AND CARRIER ON REVERSE - This notice must be filed with the CHAIR, Workers' Compensation Board, by the Insurance Company or Self-Insured Employer within 16 days after the date on which benefit payments were stopped or modified. (Please note: if this form serves as a notice of termination of temporary payment of compensation pursuant to Section 21-a WCL, it must be delivered within five days after the last payment.) This notice should be sent to the Board office in the district where the injury occurred. (See district office addresses below.) 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 I - This notice shows that your employer or its insurance company has stopped paying benefits to you or has modified the rate at which benefits are being paid. 2. The stopping or modification of payments may have been made because: a. a decision or award was made by the Workers' Compensation Board, or b. you have returned to work, or c. your employer or its insurance company contends that your disability has ended or lessened. 3. Item 16 on the front of this form shows the reason why your employer or its insurance carrier has stopped or modified your benefits. a. If the case has been closed, and all payments awarded have been made, no further action will usually be necessary unless the decision has been appealed. b. If the case has not been closed, the Board will determine if additional benefits are due and notify you in writing of any further action taken on your claim. 4. If you have not received the payments awarded by the W. C. Law Judge or the Board, or shown in item 15 on the front of this form, or have not received the benefits agreed to as the result of a conciliation agreement, contact the insurance carrier and the nearest office ofthe Workers' Compensation Board. 5. The filing of this notice by the insurance carrier does not affect your right to medical care related to your injury or occupational disease. Only the Board may determine if medical care may be terminated. IF ITEM 17 IS CHECKED - NOTICE OF TERMINATION OF TEMPORARY PAYMENTS OF COMPENSATION If item 17 on the front of this form is checked, disregard the information given in numbers 1-5 above. This form serves as notice that your employer or its insurance carrier is stopping temporary payment of compensation, which was begun voluntarily without an award from the Workers' Compensation Board. The payment of such compensation is not an admission by the employer of liability for your injury. Upon the ending of these payments, you and your employer retain all original rights, defenses and obligations under the Workers' Compensation Law without regard for the temporary payment of compensation. If the employer or carrier is now accepting liability for your claim, Form C-669 must be sent to you simultaneously with this notice. If the employer or carrier is now disputing your claim, Form C-7 must be sent to you simultaneously with this notice, or within ten days after delivery of this notice. If you do not receive one of these forms when your temporary compensation is stopped, notify the Workers' Compensation Board immediately 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 in items 1-5 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' COMPENSATIONLAW, OR THE VOLUNTEER FIREFIGHTERS OR VOLUNTEER AMBULANCE WORKERS' LAWS, YOU SHOULD CONSULT THE NEAREST OFFICE OF THE BOARDFOR ADVICE. ALWAYS USE THE CASE NUMBERS SHOWN ON THE OTHER SIDE OF THIS NOTIC E, OR ON OTHER PAPERS RECEIVED BY YOU, IF YOU FIND IT NECESSARY TO WRITE OR CALL THE BOARD. TO THE CARRIER Except in the case of payment of compensation under Section 21-a, the filing of a Form C-8/8.6 in a case where the carrier has begun payment without awaiting an award of the Board, is not authority to suspend or reduce payments in an open and pending claim unless supporting evidence accompanies the notice, such as: (1) a copy of a payroll report if the benefit rate is not based on information contained in the Report of injury and is below the maximum, and/or (2) claimant's medical and other reports (including notice of return to work), or by indicating on the Form C-8/8.6 the name and date of the claimant's medical or other reports, if they have been previously filed. See 12NYCRR300.23 of Board's Rules for other requirements controlling the right to suspend or modify payments. See 12NYCRR300.22 (d) of Board's Rules for other requirements regarding temporary payments of compensation without prejudice and without admitting liability under Sec. 21-a WCL. 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. 100 Broadway State Office Building State Office Building WORKERS' COMPENSATION BOARD DISTRICT OFFICES Menands 44 Hawley Street 180 Livingston Street 125 Main Street 455 Wheeler Rd. 175 Fulton Avenue 41 North Division St. 130 Main Street W. 935 James Street ALBANY 12241 BINGHAMTON 13901 BROOKLYN 11248 BUFFALO 14203 HAUPPAUGE 11788 HEMPSTEAD 11550 PEEKSKILL 10566 ROCHESTER 14614 SYRACUSE 13203 (58) 474-6674 (607) 721-8356 (718) 802-6600 (716) 847-3158 (516) 952-7964 (516) 560-7700 (914) 788-5775 (716) 238-8300 (315 ) 423-2934 C-8/8.6 (7-99) Reverse