NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 Statewide Fax Line: 877-533-0337 Customer Service: 877-632-4996 STATE OF NEW YORK WORKERS' COMPENSATION BOARD APPLICATION FOR REOPENING OF CLAIM, MORE THAN SEVEN YEARS AFTER ACCIDENT THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. NOTICE: This form must be filed immediately with the Chair, Workers' Compensation Board, together with attending doctor's report (Form C-27) if required, at the district office where the case was closed. Information on reverse side must be completed. ANSWER ALL QUESTIONS FULLY - PRINT OR TYPE CLEARLY W.C.B. Case No. 1. Name of injured Date of Accident Sex Claimant's Social Security No. Date of Birth Apt. No. Present address 2. Employer (at time of accident) Address 3. When did you last work for this employer? 4. Name of present attending doctor Address 5. If injured employee is deceased, give date of death 6. Nature of injury 7. State specific reasons why you desire reopening of your case 8. RECORD OF MEDICAL TREATMENT SINCE THE ACCIDENT (List all doctors and hospitals): Doctor or Hospital Address From From From Period To To To Yes No 9. Were you originally provided with any apparatus or appliances for your injury or furnished with treatment at the time of the accident? .......................................................................................... (a) If "Yes," who provided and paid for it? (b) Has such apparatus been replaced or repaired? ............................................................................ (c) If "Yes," by whom and on what date? Yes No 10. Has any medical or surgical treatment or hospital care been furnished to you by employer or insurance carrier within the last 8 years? .................................................................... 11. Has apparatu sor artificial appliance been furnished or repaired by employer or insurance carrier within the last 8 years? ......................................................................................... 12. Did you sue anyone other than filing for compensation as a result of your accident?............................ If "Yes," provide the following: Yes Yes Yes No No No Name and address of attorney Date settled Submit copy of settlement papers, if available. (Complete the information on the reverse side) Amount of Settlement: $ C-25 (1-11) C-25 C-25 C-25 C-25 C-25 C-25 American LegalNet, Inc. www.FormsWorkFlow.com 13. Has any compensation been paid to you within the past 8 years?...................................................... If "Yes," give the following information: (a) When was last payment made? (b) By whom? (c) Were you given lighter duties?...................................................................................................... (d) If Yes to (c), were benefits received for reduced earnings?.......................................................... 14. Have you sustained any other injury since the closing of your case?................................................. If "Yes," state the following: (a) Nature of such injury (b) Date of accident (c) Name of the employer (d) W .C.B. Case Number (e) Last date of hearing 15. Are you currently working?................................................................................................................. Yes No Yes Yes Yes No No No Yes Yes No No If If you are not currently working, are you retired?............................................................................ you are currently working, give the following information: (a) Name of latest employer Address Employer's NYS U.I.Registration No. (if known) (b) When did present period of disability begin? (Date) (c) Give first and last date you worked on the job immediately preceding present disability: First day worked Last day worked (d) Are you receiving disability benefits for your present period of disability?.................................... If "Yes," from whom? Yes No ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. Claimant's Signature ____________________________________ Telephone No. Mail Address Dated IMPORTANT Authorization must be received from the Chair, Workers' Compensation Board, before securing medical treatment or supplies. Otherwise, claimant will be responsible for said medical treatment or supplies. Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Sec. 552a). The Workers' Compensation Board's ("Board") authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers' Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records. The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state and federal law. The Board's Director of Operations, located at 100 Broadway, Menands, New York 12241 (518-474-6674), is primarily responsible for the maintenance of agency records containing personal claimant information. Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntary release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim. IF YOU HAVE QUESTIONS OR NEED ADVICE ABOUT YOUR CLAIM, YOU MAY CALL OR VISIT THE NEAREST OFFICE OF THE WORKERS' COMPENSATION BOARD. SI USTED TIENE ALGUNAS PREGUNTAS O NECESITA CONSEJO SOBRE SU RECLAMACION, USTED PUEDE LLAMAR O VISITAR LA OFICINA DE LA JUNTA DE COMPENSACION MAS CERCANA A USTED. C-25 (1-11) Reverse American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.ny.gov