Fill and Sign the Southern Tier Officenysedc New York State Economic Form

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. The above claim is one which may be appropriate for Conciliation processing as: - 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. ATTACH COPIES OF ALL SUPPORTING DOCUMENTS, IF NOT PREVIOUSLY SUBMITTED. The only outstanding issue(s) are: 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): Title Signature of Authorized Representative Date Signed FAX Number Printed Name of Representative Telephone Number C B-8 (1-00) 100 Broadway State Office Building State Office Building 175 Fulton Avenue Menands 41 North Division St. HEMPSTEAD 11550 PEEKSKILL 10566(516) 560-7700 (607) 721-8356 (914) 788-5775 (718) 802-6600 (516) 952-7964 935 James StreetSYRACUSE 13203(315 ) 423-2934 130 Main Street W.ROCHESTER 14614(716) 238-8300 455 Wheeler Rd.HAUPPAUGE 11788 (716) 847-3158 125 Main StreetBUFFALO 14203 180 Livingston StreetBROOKLYN 11248 44 Hawley StreetBINGHAMTON 13901 (58) 474-6674ALBANY 12241 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