Fill and Sign the Report of Injury to Volunteer Ambulance Worker for Workers Compensation New York Form

                                                                                                                       THE ABOVE-NAMED VOLUNTEER AMBULANCE THE ABOVE-NAMED VOLUNTEER MEMBER, OF ANOTHER AMBULANCE                                                                                                                                     STATE OF NEW YORK-WORKERS' COMPENSATION BOARD POLITICAL SUBDIVISION'S REPORT OF INJURY TO VOLUNTEER AMBULANCE WORKER Send this Report directly to Chair, Workers' Compensation Board at address shown on reverse side within ten (10) days after injury isincurred. Answer all questions fully. Copy also should be provided to or retained by your insurance carrier. TYPEWRITER PREPARATION IS STRONGLY RECOMMENDED - INCLUDE ZIP CODE IN ALL ADDRESSES-VOLUNTEER FIREFIGHTER'S S.S.NO . MUST BE ENTERED BELOW + WCB CASE NO. (If Known) CARRIER CASE NO. CARRIER CODE NO. VF POLICY NO. DATE OF INJURY SOCIAL SECURITY NO. W- NAME ADDRESS 1. POLITICAL SUBDIVISIONOR AMBULANCE DISTRICT 2. AMBULANCE COMPANY 3. INSURANCE CARRIER 4. NAME AND ADDRESS OF VOLUNTEER FIREFIGHTER 5. (a) SEX 5. (b) AGE 5.(c) DATE OF BIRTHI N J U R E D P E R S 0 N month day year 6. NAME AND ADDRESS OF REGULAR EMPLOYER 7. HAS INJURED AMBULANCE WORKER RETURNED TO REGULAR EMPLOYMENT Ye s No 8. WHERE DID INJURY OCCUR? (Specify in building, outside building, en route in fire truck, etc.) 9. CHECK ONE INJURED IN THE LINE OF DUTY WHILE SERVING WITH HIS/HER OWN AMBULANCE COMPANY OR AMBULANCE DEPARTMENT. DEPARTMENT, WAS INJURED IN LINE OF DUTY AFTER HIS/HER SERVICES HAD BEEN ACCEPTED BY THE ABOVE-NAMED AMBULANCE COMPANY OR DEPARTMENT. 1 0. DATE OF INJURY 11. DATE DISABILITY BEGAN 12. DATE OF FIRST KNOWLEDGE OF INJURY 13. WAS NOTICE OF INJURY GIVEN I N J U R Y IN WRITING Ye s No 14. ADDRESS WHERE INJURY OCCURRED 15. NAMES AND ADDRESSES OF WITNESSES (Attach separate sheet if necessary.) 16. NATURE OF INJURY AND PART(S) OF BODY AFFECTED: (e.g., ''INJURY TO CHEST'', etc.) Ye s No 17. DID YOU PROVIDE MEDICAL CARE? IF YES, WHEN 18. (a) NAME AND ADDRESS OF DOCTOR (b) NAME AND ADDRESS OF HOSPITAL 19. WHAT WAS AMBULANCE WORKER DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material firefighter was using.) C A U S E 0 F 20. HOW DID THE INJURY OR EXPOSURE OCCUR? (Please describe fully the events that resulted in injury or occupational disease. Tell what happened and how it happened. Please use separate sheet if necessary.) I N J U R Y 21. (a) WAS PROTECTIVE EQUIPMENT PROVIDED. (Such as gas mask, etc.) (b) WAS PROTECTIVE EQUIPMENT IN USE AT THE TIME? Ye s No Ye s No (c) WAS PROTECTIVE EQUIPMENT DEFECTIVE? Ye s No IF YES, IN WHAT WAY (Attach separate sheet if necessary). FATAL 22. (a) DATE OF DEATH (b) NAME AND ADDRESS OF NEAREST RELATIVE (c) RELATIONSHIP CASES DATE OF THIS REPORT p R E p A R A T I 0 N IF FORM IS SUBMITTED BY POLITICAL SUBDIVISION COMPLETE A & B BELOWIF FORM IS SUBMITTED BY THIRD PARTY COMPLETE A B C & D BELOW A. PERSON PREPARING FORM OR SUPPLYING INFORMATION B. TITLE TELEPHONE NUMBER & EXTENSION C. IF REPORT PREPARED BY THIRD PARTY, COMPANY NAME AND ADDRESS D. THIRD PARTY CONTACT NAME TELEPHONE NUMBER & EXTENSION VAW-2 (3-99) VAW-2 VAW-2 VAW-2 VAW-2 ALBANY 12241 - 1 00 Broadway, Menands. (518) 474-6674 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, INSTRUCTIONS TO POLITICAL SUBDIVISIONS AND UNAFFILIATED AMBULANCE SERVICES: reports should be sent directly to the district offices at these addresses: addresses: Greene, Hamilton, Montgomery, Orange, Putnam, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (607) 721-8356 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - State Office Building, 125 Main Street. (716) 847-3158 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara.HEMPSTEAD 11550 - 175 Fulton Avenue. (516) 560-7700 For all accidents in following counties: Nassau, Suffolk.NEW YORK CITY 11248 - 180 Livingston Street, Brooklyn. (718) 802-6600 For all accidents in following counties: Bronx, Kings, New York, Queens, Richmond, Rockland, Westchester. ROCHESTER 14614 - 130 Main Street West. (716) 238-8300 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca ,Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (315) 423-2934 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. LIABILITY FOR BENEFITS AND DUTY TO COMPLETE AND FILE THIS REPORT - VOLUNTEER AMBULANCE WORKERS' LAW Section 42. Reports of injuries, claims and proceedings. If an injury is one for which an insurance carrier might be liable under a contract of insurance or a county plan of self-insurance might be required to pay, the officer to whom a notice of injury isrequired to be delivered or mailed and with whom the claim in relation to such injury is required to be filed under the provisions of thischapter shall send a copy of such notice and claim and a copy of any notice of a proceeding relating to an injury or claim to suchinsurance carrier or county plan of self-insurance, as the case may be, promptly after receiving the same. The political subdivision liablefor the payment of benefits under this chapter shall keep such records and make such reports to the chair of the workers' compensationboard as required by article seven, section one hundred ten, of the workers' compensation law, which by section fifty-seven of thischapter is made applicable to this chapter. Failure to comply with the provision of this section shall not relieve such an insurance carrierof liability or a county plan of self-insurance from its obligation to pay. (See below excerpt of Article 7, Section 110, of the Workers' Compensation Law). Section 50. Payments pending controversies. In order that the benefits to be paid and provided under this chapter shall be paid promptly where such benefits are conceded to be due to any person because of the death of or injuries to a volunteer firefighter, butcontroversy exists as to which political subdivision is liable for the payment thereof, the municipal corporations and fire districts involvedin such controversy and their insurance carriers, if any, may agree that any one or more of such municipal corporations or fire districts orits insurance carrier shall pay or provide the benefits to, or in relation to, the person conceded to be entitled to such benefits withoutwaiting for a final determination of the controversy, and may carry out the provisions of such an agreement. Notwithstanding any suchpayment, any party to the agreement may seek a final determination of the controversy in the same manner as if such benefits had notbeen paid or provided and any such payment or provision of benefits shall not prejudice any rights of the political subdivision or itsinsurance carrier paying or providing the same, nor be taken as an admission against interest. After a final determination the parties tothe agreement shall make any necessary and proper reimbursement to conform to the determination. WORKERS' COMPENSATION LAW Section 110. Record and report of injuries by employers*.1. An employer, or a third party designated by the employer, shall record any injury or illness incurred by one of its employees in the course of employment using the form prescribed by the chair for reporting injuries under subdivision two of this section. Such form, acopy of which shall be provided to the injured employee upon request, shall be maintained by the employer, or a third party designatedby the employer, for at least eighteen years, and shall be subject to review by the chair at any time. Such form need not be filed with thechair unless the status of such injury or illness changes resulting in a loss of time from regular duties or in medical treatment whichwould require reporting in accordance with subdivision two of this section. 2. An employer, or a third party designated by the employer, shall file with the chair of the workers' compensation board and with the carrier if the employer is insured, upon a form prescribed by the chair, a report of any accident resulting in personal injury whichhas caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident occurred, orwhich has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid.Such report shall state the name and nature of the business of the employer, the location of its establishment or place of work, the name,address and occupation of the injured employee, the time, nature and cause of the injury and such other information as may be requiredby the chair. Such report shall be filed within ten days after the occurrence of the accident. An employer shall furnish a report of anoccupational disease incurred by an employee in the course of his or her employment, to the chair of the workers' compensation board,and to the carrier if the employer is insured, upon the same form. The carrier, within fourteen days of receipt of the report oraccompanying the initial check forwarded to the employee, whichever is earlier, or a self-insured employer, within fourteen days oftransmitting the report to the chair or accompanying the initial check forwarded to the employee, whichever is earlier, shall provide theinjured employee or, in the case of death, his or her dependents with a written statement of their rights under this chapter, in a formprescribed by the chair. An employer shall file a report of any other accident resulting in personal injury incurred by its employee in the course of employment, upon the same form, whenever directed by the chair. 3. Any injury or illness which is not required to be reported in accordance with subdivision two of this section, shall not be used as a basis for determining experience modification rates, provided the employer pays in the first instance or reimburses the employer's insurer for the treatment rendered to the employee. 4. An employer who refuses or neglects to make a report or to keep records as required by this section shall be guilty of a misdemeanor, punishable by a fine of not more than one thousand dollars. The board or chair may impose a penalty of not more thantwo thousand five hundred dollars upon an employer who refuses or neglects to make such report. 5. The chair shall be authorized to promulgate regulations necessary to carry out the provisions of this section. * In volunteer ambulance workers' benefit cases, the liable political subdivision or unaffiliated ambulance service is deemed to be the ''employer'' of the ambulance worker. THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. VAW-2 (3-99) Reverse