Fill and Sign the New York Notice Claim Form

7. EMPLOYER8. CARRIER                                                                                   Nature and Extent       Date of Onset:       No Yes                   Form C-2 filed on:       Claimant's Date of Birth:       A.W.W.             If death, provide date of death:             Compensation has been paid from                                     - - NOTICE OF CLAIM FOR REIMBURSEMENT OUT OF THE SPECIAL DISABILITY FUND UNDER SECTION 15, SUBD. 8 ANSWER ALL QUESTIONS FULLY ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. CASE NUMBER 2. CARRIER CASE NUMBER 3. CARRIER CODE4. DATE OF INJURY 5. SOCIAL SECURITY NUMBER NAM E A D D R E S S 6. INJURED Apt. No. PERSON The carrier on behalf of the above-named employer is requesting apportionment of any liability that may be awarded for compensation or medical expenses on this claim and an order directing reimbursement pursuant to Workers' Compensation Law, Section 15 (8). The following information is furnished in support of this notice and claim, subject to further development of the record: 9. Previous physical impairment(s): 10. Subject of WC Claim: If yes, provide particulars (WCB Case No., Name of Employer, Carrier) Subject of Court Action: No Yes If yes, provide particulars (e.g., Date, Court, Index No.) 11. Details of present claim: Description of Injury: Nature of injury which caused the death: to Payments are are not continuing. By Name Title Date Telephone No. MAIL THIS FORM TO THE WORKERS' COMPENSATION BOARD For all downstate claims (NYC, Hauppauge, Hempstead, Peekskill), mail to: PO Box 5205, Binghamton, NY 13902-5205. For upstate claims, mail to the district office where the claim was filed. THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. C-250 (6-06) Prescribed by ChairWorkers' Compensation BoardState of New York www.wcb.state.ny.us