Fill and Sign the Ny Workers Compensation Form

                                                                                                   a. Medical reports showing change of condition on and after b. Other                                                 WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER ANSWER ALL QUESTIONS FULLY ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. District Office Name Address to which notices should be sent (Give Number and Street, City, State, and Zip Code) 6. Injured Social Security No. Apt. No. Person 7. Employer* 8. Carrier 9. Date of Direction to ContinuePayments (Award Date) 10. Rate Fixed 11. Date Most Recent Payment Mailed *In volunteer firefighters' and volunteer ambulance workers' benefit cases, the liable political subdivision(or unaffiliated ambulance service as defined in Sec. 30 VAWBL ) is deemed to be the "EMPLOYER."REASON FOR REQUEST PAYMENTS ARE BEING CONTINUED AT THE RATE FIXED PENDING CONSIDERATION OF THE ATTACHED EVIDENCE. Carrier contends that payments should be: SUSPENDED or REDUCED TO $ per week based on the following evidence: (copy to his/her health provider) I hereby affirm that a copy of this notice with attachment(s) was sent to the CLAIMANT, to other appropriate parties of interest and to his/her REPRESENTATIVE, if any, on this date. Dated Prepared by Telephone No. and Extension Title PAYMENTS MUST CONTINUE AT THE RATE FIXED PENDING DETERMINATION BY BOARD THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION C-22b (1-01) Prescribed by Chair Workers' Compensation Board State of New York SEE REVERSE FOR IMPORTANT INFORMATION IMPORTANT INFORMATION 1 . The Insurance Company or Self-Insured Employer must file this notice, with appropriate proof attached, with the CHAIR, Workers' Compensation Board, in the district office where the case is pending. Simultaneously, a copy of the notice and proofs must be sent to the CLAIMANT, to his/her DOCTOR and to his/her REPRESENTATIVE, if any. 2. This notice may be filed in any case where there has been an award and a direction for continuation of payments and evidence is presented (see attachment) to support the suspension of payments or reduction in rate. 3. The Board, upon receipt of this notice and attachments, may either schedule a WC LAW JUDGE HEARING on this issue within 20 days during any period in which regular hearings are scheduled, or refer the matter to the Office of Appeals for a determination of whether a reopening is warranted. In the event that the Office of Appeals directs that the case be reopened, a WC Law Judge Hearing will be scheduled in an expedited manner. 4. Cases at hearing points which do not have regularly scheduled hearings within 20 days may be scheduled at another hearing point. 5. At the time a WC Law Judge hearing is held, either immediately after the Board's receipt of this notice and attachments or at the direction of the Office of Appeals, the WC Law Judge will consider all available evidence and decide whether or not payments may be suspended or reduced. 6. PAYMENTS SHALL CONTINUE, AS DIRECTED, until there is a determination by the WC Law Judge that such payments may be suspended or reduced. TO THE CLAIMANT 1 . Please read this notice and attachments carefully. This notice means that your employer (if self-insured) or his/her insurance company wants to suspend or reduce your compensation payments, for the reason indicated. 2. As explained above, your case may be scheduled for a hearing on this issue. Be sure to BE PRESENT, if you disagree with your employer or his/her insurance company. If you are NOT PRESENT, the W.C. Law Judge will make a decision based on available evidence. If your employer or his/her insurance company contends that your compensation payments should be suspended or reduced because your medical condition has improved (not because your earnings have increased), BRING YOUR DOCTOR'S REPORT DESCRIBING YOUR CONDITION TO THE HEARING. 3. If you have an ATTORNEY or REPRESENTATIVE, show him/her this notice and consult with him/her regarding your rights under the law. 4. If you have any question concerning this notice or in connection with your case, contact the nearest office of the Board. ALWAYS USE THE WCB CASE NUMBER SHOWN ON THE OTHER SIDE OF THIS NOTICE, or on other papers received by you, if you find it necessary to communicate with the Board or the carrier. TO THE CARRIER 1 . Send this notice with attachments to the Claims Bureau in the district office of the Board where the case is pending. Misrouting may CAUSE DELAY in scheduling a hearing. 2. IF REQUIRED PROOFS ARE NOT ATTACHED, THE CASE WILL NOT BE SCHEDULED FOR HEARING. Section 114 of the Workers' Compensation Law provides, in part, that any employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who knowingly makes a false statement or representation as to a material fact for the purpose of avoiding provision of any payment or benefit under this chapter shall be guilty of a felony. 100 Broadway State Office Building Statler Towers Menands 44 Hawley Street 107 Delaware Ave. 130 Main Street W. 935 James Street ALBANY 12241 BINGHAMTON 13901 BUFFALO 14202 ROCHESTER 14614 SYRACUSE 13203 (518) 474-6674 (607) 721-8356 (716) 842-2166 (716) 238-8300 (315 ) 423-2932 C-22b Reverse (1-01)