STATE OF NEW YORK WORKERS' COMPENSATION BOARD NOTICE TO LIABLE POLITICAL SUBDIVISION OF VOLUNTEER FIREFIGHTER'S INJURY OR DEATH THIIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. THIS NOTICE IS REQUIRED TO BE FILED WITHIN 90 DAYS AFTER THE DATE OF INJURY OR DEATH UNLESS CLAIM FOR BENEFITS, INCLUDING MEDICAL, HOSPITAL OR OTHER CARE, (VF-3 or VF-62) IS FILED WITHIN 90 DAYS AFTER THE DATE OF INJURY OR DEATH. Sec.40 of the Volunteer Firefighters' Benefit Law provides that, unless Claim for Benefits is filed within 90 days after injury or death, Notice of such injury or death shall be given by delivery in person or by registered mail within 90 days by the injured volunteer firefighter or by any person claiming to be entitled to benefits, or by someone in his/her behalf, to the designated officer of the liable political subdivision as follows: If the political subdivision liable for benefits is a a. County b. City c. Town d. Village e. Fire District Then give to a. Clerk of the Board of Supervisors b. Comptroller or Chief Financial Officer c. Town Clerk d. Village Clerk e. Secretary If your injury occured prior to March 1, 1964, the injury should be reported to the county, city, town, village or fire district for which the service was rendered whether such service was rendered for the home area or for another area under contract or in response to a call for assistance. If the injury occured on March 1, 1964 or thereafter, the home county, city, town, village or fire district is liable for thr payment of benefits regardless of whether the injury was incurred while serving your home area or an aided area. If you have any doubt concerning the liable political subdivision, a copy of this notice should be filed with all the political subdivisions involved. THIS NOTICE IS NOT A CLAIM FOR BENEFITS. FAILURE TO FILE THE CLAIM FOR BENEFITS (FORM VF-3 or VF-62) WITHIN TWO YEARS AFTER INJURY OR DEATH MAY BAR YOU FROM RECEIVING BENEFITS. To: _____________________________________________________________________________________________________ Name of Officer First Name Middle Initial Title of Officer Last Name Political Subdivision Liable for Benefits Home Address Apt. No. 1. VOLUNTEER FIREFIGHTER Name Address 2. FIRE COMPANY 3. POLITICAL SUBDIVISION OR FIRE DISTRICT 4. REGULAR EMPLOYER, IF ANY 5. Address and community where injury occurred_____________________________________________________________________ __________________________________________________________________________________________________________ 6. (a) Date of injury__________________________ at_____o'clock____M. (b) Date of death______________________________ (c) Place of death____________________________________________________________________________________________ 7. State fully nature and cause of injury or death_____________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Dated______________________________ Signed by______________________________________________, or Volunteer Firefighter Signed by__________________________________________________________________________________________________ A person on his/her behalf, or in case of death, by any one or more of his/her dependents, or by a person on their behalf. Relationship VF-1 (8-97) 2001 © American LegalNet, Inc.