Carriers Request For Benefit Increase Reimbursement (§ 51)
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Carriers Request For Benefit Increase Reimbursement (§ 51) Form. This is a New York form and can be use in Workers Compensation.
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Tags: Carriers Request For Benefit Increase Reimbursement (§ 51), VF-VAW-10, New York Workers Compensation,
State of New York
WORKERS' COMPENSATION BOARD
VF/VAW ADJUSTMENTS
CARRIER'S REQUEST FOR BENEFIT INCREASE REIMBURSEMENT UNDER SECTION 51
VOLUNTEER FIREFIGHTERS' & VOLUNTEER AMBULANCE WORKERS' BENEFIT LAWS
WCB Case No.
Carrier Case No.
Claimant
Social Sec. No.
Carrier:
Vol. Fire Claim
Vol. Ambulance Claim
Carrier Address:
Original weekly benefit rate in this claim: $_________ Increased benefit rate effective Jan. 1, 1999: $_________
Original weekly benefit rate in this claim: $_________ Increased benefit rate effective July 27, 2004: $_________ (VAW ONLY)
Original weekly benefit rate in this claim: $_________ Increased benefit rate effective Jan. 2, 2006: $_________
The Carrier requests reimbursement for benefits paid, as follows:
A.
Compensation/Death Benefits
Weeks from
To
at $
/wk
$
Weeks from
To
at $
/wk
$
Weeks from
To
at $
/wk
$
B.
Lump Sum
C.
Re-marriage Award
$
................................................................................................................
................................................................................................................
$
TOTAL OF THIS CLAIM FOR REIMBURSEMENT
Yes
$
1.
Does this represent an initial request for reimbursement in this claim?
No
2.
If this is the initial request for reimbursement, or re-marriage award, you must attach the following:
a.
A copy of the Notice of Decision establishing the classification and benefit rate or award.
b.
A copy of Form C-8/8.6 verifying the rate change.
CARRIER STATEMENT
I hereby certify that this request for reimbursement made to the Chair of the Workers' Compensation Board is true and correct;
that no part thereof has been previously paid and that the amount stated therein is due and owing.
By (Print or Type):
Signature:
Telephone No.
Title:
Date:
INSTRUCTIONS:
1. Claims for compensation reimbursement should be submitted for 52-week periods.
2. Forward original and one copy, along with any required documentation to:
WORKERS' COMPENSATION BOARD
FUND FOR REOPENED CASES UNIT - ROOM 312
20 PARK ST, ALBANY NY 12207
3. Retain one copy for your records.
VF/VAW-10 (10-06)
www.wcb.state.ny.us
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