Fill and Sign the New York Notice Death Form

To:                                                                  5 Address and community where injury occurred                                       (c) Place of death       7. State fully nature and cause of injury or death                         Signed by       Signed by             STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUTDISCRIMINATION. NOTICE TO LIABLE POLITICAL SUBDIVISION OF VOLUNTEER FIREFIGHTER'S INJURY OR DEATH THIS NOTICE IS REQUIRED TO BE FILED WITHIN 90 DAYS AFTER THE DATE OF INJURY OR DEATH UNLESS CLAIM FOR BENEFITS, INCLUDING MEDICAL, HOSPITAL OR OTHER CARE, (VF-3 or VF-62) IS FILED WITHIN 90 DAYS AFTER THE DATE OF INJURY OR DEATHSec. 40 of the Volunteer Firefighters' Benefit Law provides that, unless Claim for Benefits is filed within 90 days after injury or death, Notice of such injury or death shall be given in person or by registered mail, within 90 days by the injured volunteer firefighter or by any person claiming to be entitled to benefits, or by someone in his/her behalf, to the designated office of the liable political subdivision as follows: If your injury occurred prior to March 1, 1964, the injury should be reported to the county, city, town, village or fire district for which the service was rendered whether such service was rendered for the home area or for another area under contract or in response to a call for assistance. If the injury occurred on March 1, 1964 or thereafter, the home county, city, town, village or fire district is liable for the payment of benefits regardless of whether the injury was incurred while serving your home area or an aided area. If you have any doubt concerning the liable political subdivision, a copy of this notice should be filed with all the political subdivisions involved. THIS NOTICE IS NOT A CLAIM FOR BENEFITS. FAILURE TO FILE THE CLAIM FOR BENEFITS (FORM VF-3 or VF-62) WITHIN TWO YEARS AFTER INJURY OR DEATH MAY BAR YOU FROM RECEIVING BENEFITS Name of Officer Title of Officer Political Subdivision Liable for Benefits First Name Middle Initial Last Name Home Address Apt. No. 1 VOLUNTEER FIREFIGHTER Name Address 2 FIRE COMPANY 3 POLITICAL SUBDIVISION OR FIRE DISTRICT 4 REGULAR EMPLOYER, IF ANY 6. (a) Date of injury at o'clock M. (b) Date of death Dated , or Volunteer Firefighter A person on his/her behalf, or in case of death, by any one or more of his/her dependents, or person on their behalf. Relationship VF-1 (8-97)