STATE OF NEW YORKWORKERS' COMPENSATION BOARDCARRIER'S REQUEST FOR REIMBURSEMENT OF COMPENSATION PAYMENTS UNDER SEC. 15-8WCB CASE NO.CARRIER CASE NO.CARRIER ID NO. WSOC. SEC. NO.CARRIER'S ADDRESS CARRIER'S NAMECLAIMANT'S NAMEThe Carrier requests reimbursement for benefits paid, as follows:A. weeks from to at $ $ weeks from to at $ $ weeks from to at $ $ B. Lump sum payment representing weeks at $ per week. $ C. Funeral Expenses $ D. Other (Specify) $ TOTAL CLAIM FOR REIMBURSEMENT $1. Does this claim represent an initial request for reimbursement of compensation payments ?YesNo2. Date Claimant's status was last checkedThe summary below is to be used for all initial claims. If desired, Form C-8/8.6 may be substituted and attached to the original copy. The summary (or Form C-8/8.6) must include all payments from date of accident through the period for which reimbursement is requested.SUMMARY OF COMPENSATION PAYMENTSLess Days WorkedNumber of WeeksWeekly RatePeriod(s) of Payments FromTo3. Is there a third party action on this claim?YessettleddismissedpendingIf yes, is this actionNoS T A T E M E N TI 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 the amount stated therein is due and owing. Signature: Date: Title: Telephone No.:DO NOT USE SPACE BELOWINSTRUCTIONS:1. Where possible, claim should be submittedTO: CHAIR, WORKERS' COMPENSATION BOARDThe Special Funds Conservation Committee approves reimbursement for the above claim totaling $.for 26 week periods. 2. Forward original and two copies to the local officeAgreed Date for Compensation Reimbursementof the Special Funds Conservation Committee. 3. Retain one copy.ByDateC-251 (11-01)2002 © American LegalNet, Inc.