Fill and Sign the Ny Request Form

                             work on account of disability, which resulted from accidental injury or occupational disease, sustained by h                   These wages covered the period from       at the rate of $       weekly, $       $       The undersigned employer, for moneys advanced during the above noted period of absence, hereby The undersigned employer, for moneys advanced during the above noted period of absence, hereby       The undersigned employee acknowledges receipt of wages paid by my employer,       on                   EMPLOYER'S REQUEST FOR REIMBURSEMENT AND EMPLOYEE'S ACKNOWLEDGEMENT OF RECEIPT OF WAGES W.C.B. CASE NO. CARRIER CLAIM NO. To Be Completed by Employer: The undersigned employer has advanced wages to during the absence from o n to monthly, amounting to in total.TO THE WORKER'S COMPENSATION BOARD: A. requests reimbursement in full. B. requests reimbursement at the compensation rate. Date Employer TO BE COMPLETED BY EMPLOYEE: • during my absence from work on account of disability which resulted from accidental injury or occupational disease sustained by me I acknowledge that these wages covered the period indicated above and were in the amount stated above. Date Employee CK0056 12- 96 I -- NOTICE -- 1. This form is used as evidence of a claim for reimbursement by an employer for moneys advanced to a claimant on account of compensation due, under the provisions of the Workmen's Compensation Law. 2. NOTE TO EMPLOYER: '',1 ~ Please note that under current interpretations of Section 25 of the Workmen's Compensation Law, in cases involving temporary disability, an employer may not recover more than the compensation benefit rate for the period during which compensation or wages were advanced, nor may there be any reimbursement for the first week if the disability does not exceed (2) weeks. 3. Attention is directed specifically to Section 25 of the Workmen's Compensation Law, from which the following is extracted: . ... If the employer has made advance payments of compensation, or has made payments to an employee in like manner as wages during any period of disability, he shall be entitled to be reimbursed out of an unpaid installment or installments of compensation due, provided his claim for reimbursement is filed before award of compensation is made, or, if insured, by the insurance carrier at the direction of the board, unless he shall file a waiver of reimbursement with the chairman, in which event compensation will be paid to the claimant notwithstanding the advance payments ... 4. In addition, form EC-84, Computer-Generated Notice of Indexing, which is sent to the carrier in each indexed case, contains the following directions regarding reimbursement: "in cases where wages are paid by the employer as an advance payment of compensation, and where reimbursement is or will be sought, you are hereby directed to file with the board, before award of compensation is made, proof of claim of reimbursement consisting of receipts of advance payments of compensation signed by the claimant and written request for reimbursement signed by the employer showing the amount of advance payments made, the period of disability for which payments were made, the dates of such payments, and the amount requested as reimbursement." - - INSTRUCTIONS -- 1. To request reimbursement, in whole or in part, complete this form and return it to us immediately. 2. If the employee is entitled to benefits for temporary and permanent disability you may request full reimbursement up to the amount of compensation payable. To do this, check the block marked "A". 3. If you wish reimbursement only at the compensation rate for temporary disability, check the block marked "B". 4. If request for reimbursement is not made prior to an award, the total compensation payable will be paid to the employee, in addition to any wages paid. 5. In showing the period for which you are requesting reimbursement, show the first date of disability and the last date on which wages were paid. 6. If employee to whom wages were paid is still in your employ, have that person sign where indicated on the front of this form. This will be their acknowledgement of the receipt of wages paid by you during their disability. Their signing of this form will not affect/jeopardize their case in any other manner. Please return the completed form as soon as possible. 7. If the employee to whom wages were paid is no longer in your employ, complete the part that pertains to you. Return the form to us with a note attached to that effect. We will obtain the former employee's signature.