Fill and Sign the Notice of Volunteer Ambulance Workers Injury or Death for Workers Compensation New York Form

To:                                                                  5 Address and community where injury occurred                                       (c) Place of death       7. State fully nature and cause of injury or death                                           STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUTDISCRIMINATION. NOTICE TO LIABLE POLITICAL SUBDIVISION OR UNAFFILIATED AMBULANCE SERVICE OF VOLUNTEER AMBULANCE WORKER'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, (VAW-3 or VAW-62) IS FILED WITHIN 90 DAYS AFTER THE DATE OF INJURY OR DEATH or death, notice of such injury or death shall be given delivery in person or by registered mail within 90 daysSec. 40 of the Volunteer Ambulance Workers' Benefit Law provides that, unless claim for benefits is filed within 90 days after injury by the injured volunteer ambulance worker or by any person claiming to be entitled to benefits, or by someone in his/her behalf to the designated,officer of the liable political subdivision as follows: If at the time of injury the volunteer ambulance worker was a member of a voluntary service which was not affiliated with a county, city, town, village or ambulance district, this notice is to be filed with the ambulance service in which he or she served. However,please note that such unaffiliated services are not required to have coverage under the Volunteer Ambulance Workers' Benefit Law. THIS NOTICE IS NOT A CLAIM FOR BENEFITS. FAILURE TO FILE THE CLAIM FOR BENEFITS (FORM VAW-3 or VAW-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 AMBULANCEWORKER Name Address 2 AMBULANCE COMPANY 3 POLITICAL SUBDIVISION OR AMBULANCE DISTRICT,IF ANY 4 REGULAR EMPLOYER, IF ANY 6. (a) Date of injury at o'clock M. (b) Date of death Dated Signed by , or Voluntary Ambulance Worker Signed by Relationship VAW A person on his/her behalf, or in case of death, by any one ormore of his/her dependents, or by a person on their behalf. - 1 (8-97)