STATE OF NEW YORK WORKERS' COMPENSATION BOARD BIANNUAL RECERTIFICATION TO ENTITLEMENT TO BENEFITS Instructions to claimants: Please read the entire form below carefully. The information and certification on this form is required by the New York State Workers' Compensation Board Rules and Regulations (12 NYCRR 304). The information and certification requested are required for the carrier or self-insured employer to continue to accommodate your wishes to have your compensation payments sent directly to your Financial Institution. After you have read the form in its entirety please print the information requested in the box below and then date and sign the bottom of the form. Thereafter return the form to your carrier and/or self-insured employer. Claimant's Name Date of Accident Carrier Case Number WCB Case Number BY EXECUTING THIS FORM THE CLAIMANT CERTIFIES TO THE FOLLOWING: 1) That he or she is entitled to the compensation payments received in the prior six months; 2) That circumstances which would affect entitlement to such benefits have not changed. Such change in circumstances includes, but is not limited to: 1) a change in employment status such as from not working to working full or part time (regardless of whether at light or full duty), from working part time to full time and from light or modified duty to regular duty AND 2) a change in medical condition as reflected in a statement by the claimant's treating medical practitioner after examination of the claimant given to the claimant; 3) That if circumstances do so change he or she will immediately notify the Chair, and the Carrier and/or the self-insured employer of such change and; 4) That he or she is aware of the provisions of Workers' Compensation Law §114-a AND Workers' Compensation Law §132 contained on the back of this form. I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE. Signed By:________________________________ Claimant Date________________ DD-2 (9-05) DO NOT SCAN www.wcb.state.ny.us American LegalNet, Inc. www.USCourtForms.com Workers' Compensation Law § 114-a. Disqualification for false representation. 1. If for the purpose of obtaining compensation pursuant to section fifteen of this chapter, or for the purpose of influencing any determination regarding any such payment, a claimant knowingly makes a false statement or representation as to a material fact, such person shall be disqualified from receiving any compensation directly attributable to such false statement or representation. In addition, as determined by the board, the claimant shall be subject to a disqualification or an additional penalty up to the foregoing amount directly attributable to the false statement or representation. Any penalty monies shall be paid into the state treasury. 2. If with the knowledge of a claimant, another person knowingly makes a false statement or representation as to a material fact for the purpose of assisting a claimant in either obtaining, or influencing any determination regarding compensation pursuant to section fifteen of this chapter, such claimant may be disqualified from receiving any compensation directly attributable to such false statement or representation. In addition, as determined by the board, the claimant may be subject to a disqualification or an additional penalty up to the foregoing amount directly attributable to the false statement or representation. Any penalty monies shall be deposited to the credit of the general fund of the state. Worker's Compensation Law § 132. Criminal prosecution; certifications. 1. The attorney-general may prosecute every person charged with the commission of a criminal offense in violation of this chapter, or of any rule, regulation or order made thereunder, or in violation of the laws of this state, applicable to or arising out of any provision of this chapter or any rule, regulation or order made thereunder. 2. Every check or draft issued directly to a benefit recipient or provider of health services in payment of a claim made pursuant to this chapter shall contain a printed statement on the reverse side immediately above the signature line for the first endorsement indicating that in endorsing the check or draft for payment the benefit recipient or provider of health services is certifying that such person is entitled to such payment and that circumstances which would affect entitlement to receive the payment have not changed. The statement shall be in a form prescribed by the workers' compensation board after consultation with the superintendent of insurance. 3. The check or draft described in subdivision two of this section shall be claim forms within the meaning of section 176.00 of the penal law and subsection (d) of section four hundred three of the insurance law. DD-2 Reverse (9-05) American LegalNet, Inc. www.USCourtForms.com