Fill and Sign the New York State Workers Comp Form

                                                                                   - Claimant's lost time or reduced earnings is not expected to exceed 52 weeks. - Claim may result in a schedule award not expected to exceed 52 weeks. - Claimant was 18 years of age or older when injured. - Claim does not require testimony to resolve outstanding issues. - Claim is not controverted. Period of compensable lost time and/or reduced earnings (include relevant C-11 or RE payroll). Degree of disability--including partial disability (attach relevant medical reports). Degree of permanency, including Schedule Loss of Use (attach copy of permanency evaluation). Computation of Average Weekly Wage (attach Form C-240, or other supporting payroll information). Disputed Medical Bills (attach copies of Form C-8.1 Part B and related bills/reports). Liability for Treatment (attach copy of Form C-8.1 Part A and supporting medical evidence). Other (please specify):                                                 100 Broadway State Office BuildingState Office BuildingMenands 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 State of New York WORKERS' COMPENSATION REQUEST FOR CONCILIATION IMPORTANT: FILE THIS FORM WITH THE CLAIMS UNIT AT THE OFFICE WHERE THE CASE IS BEING PROCESSED. WCB CASE NUMBER DATE OF ACCIDENT CARRIER CASE NUMBER CARRIER CODE NUMBER CLAIMANTS SOC SEC NO. Name Address 1.EMPLOYER 2.INSURANCE CARRIER 3. CLAIMANT The above claim is one which may be appropriate for Conciliation processing as: ATTACH COPIES OF ALL SUPPORTING DOCUMENTS, IF NOT PREVIOUSLY SUBMITTED. The only outstanding issue(s) are: Signature of Authorized Representative Titl e Date Signed Printed Name of Representative Telephone Number FAX Number C B-8 (1-00)