Print Form Clear Form PO Box 5205 Binghamton, NY 13902-5205 Customer Service Toll-Free Line: 877-632-4996 Statewide Fax Line: 877-533-0337 www.wcb.ny.gov WORKERS' COMPENSATION W.C.B. CASE NO______________________________ CARRIER CASE NO ____________________________________ CLAIMANT'S SOC.SEC.NO.______________________ CHECK ONE: VOLUNTEER FIREFIGHTERS VOLUNTEER AMBULANCE WORKERS CLAIM FOR COMPENSATION AND NOTICE OF COMMENCEMENT OF THIRD PARTY ACTION (This notice must be served on the Chair, Workers' Compensation Board, the Employer and Employer's Insurance Carrier within 30 days after action has been commenced.) 1. Name of Injured or Deceased___________________________________________________________________________ 2. Address____________________________________________________________________________________________ (Street and Number) (City or town) (State) (Zip Code) 3. Name of *Employer___________________________________________________________________________________ * In Volunteer Firefighters' and Volunteer Ambulance Workers' Benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in Sec. 30,VFBL or Sec. 30 VAWBL) is deemed to be the "EMPLOYER". 4. Address____________________________________________________________________________________________ (Street and Number) (City or town) (State) (Zip Code) 5. Employer's Ins. Carrier________________________________________________________________________________ 6. Address____________________________________________________________________________________________ (Street and Number) (City or town) (State) (Zip Code) 7. Date of Accident________________________ 8. Place of Accident____________________________________________ 9. Cause of Accident____________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 10. Nature of Injury______________________________________________________________________________________ ____________________________________________________________________________________________________ 11. Name of Attending Doctor or Hospital_______________________________12. Address____________________________________________ 13. Action commenced on____________________________in the___________________________________________court of (Month, Day and Year) ___________________________County, State of_______________, against______________________________________ (Name of 3rd Party) 14. Name of my Attorney______________________________________Tel No.______________________________________ 15. Address____________________________________________________________________________________________ I, (we) the undersigned, hereby give notice that action has been commenced against a third party or parties and hereby make claim for all benefits due me (us) under the Workers' Compensation Law. This notice is given pursuant to the provisions of Section 29 of the Workers' Compensation Law as amended (Section 20, VFBL and Section 20, VAWBL). 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. Dated __________________Signature of Claimant____________________________________Tel. No._________________________ IF CLAIM IS MADE FOR DEATH BENEFITS DEPENDENTS MUST COMPLETE THIS SIDE AND THE REVERSE SIDE OF THIS FORM. SEE REVERSE SIDE FOR INFORMATION TO CLAIMANT. C-121 (1-11) THIS AGENCY EMPLOYES AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. American LegalNet, Inc. www.FormsWorkFlow.com IN DEATH CASES COMPLETE THE FOLLOWING 1. Date of Death___________________________ 2. Cause of Death_______________________________________________ _____________________________________________________________________________________________________ 3. Name of Last Attending Doctor or Hospital___________________________________4. Address__________________________________________ (All dependents desiring to sue third party sign below): ______________________________________________________________________________________________________ (Name) (Name) (Name) (Name) (Address) (Address) (Address) (Address) (Date of Birth) (Date of Birth) (Date of Birth) (Date of Birth) (Relationship to Deceased) (Relationship to Deceased) (Relationship to Deceased) (Relationship to Deceased) ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ INFORMATION TO CLAIMANT If an employee, in the course of employment, is injured or killed because of the negligence or fault of anyone other than a co-worker (or employee of employer's insurance carrier or employees' union), s(he) or his/her statutory dependents may accept workers' compensation benefits and also sue the other person, who caused the injury or death. Such other person is called the THIRD PARTY and any lawsuit or other proceedings against him/her is referred to as a THIRD PARTY ACTION. This third party action must be commenced within six months after the award of compensation but not later than one year after the accident occurred (for exception see "ASSIGNMENT" below). The employer (or its insurance carrier) will have a lien on the net recovery actually collected by the claimant from the third party, to the extent of the compensation paid and medical costs incurred. WITHIN THIRTY DAYS AFTER COMMENCING THE THIRD PARTY ACTION, A COPY OF THIS FORM, COMPLETED AND SIGNED BY YOU MUST BE GIVEN TO EACH OF THE FOLLOWING: 1. THE CHAIR OF THE WORKERS' COMPENSATION BOARD. 2. THE EMPLOYER. 3. THE EMPLOYER'S INSURANCE CARRIER, IF ANY. ASSIGNMENT If the claimant does not sue and the employer or insurance carrier serves a written notice on the claimant, in person or by registered mail, 30 days before the end of the one year period, the claimant's right to the Third Party Action will become assigned to the employer, UNLESS, the claimant