| Title |
Last Updated |
| Consent To NYS Workers Compensation Board Jurisdiction For Non-New York Licensed Carriers (3C Coverage) |
December 2, 2010 |
| Section 110-a Affirmation-Affidavit |
November 8, 2010 |
| Notice Of Claim For Reimbursement Out Of Special Disability Fund |
November 8, 2010 |
| Electronic Attachment |
November 8, 2010 |
| Statement Of Unresolved Issues-Special Part For Expedited Hearings |
November 8, 2010 |
| Notice To Liable Political Subdivision Or Unaffiliated Ambulance Service |
November 8, 2010 |
| Notice To Liable Political Subdivision Of Volunteer Firefighters Injury Or Death |
November 8, 2010 |
| Notice Of Election To Provide WC Benefits To Participants In A Sheltered Workshop |
November 8, 2010 |
| Carriers Report On Rehabilitation To Chair Workers Compensation Board |
November 8, 2010 |
| Self Insurers Representatives Bond |
August 28, 2009 |
| Application for Certificate Of Attestation Of Exemption From New York State Workers Compensation And-Or Disability Benefits Insurance Coverage |
May 13, 2009 |
| Limited Release Of Health Information (HIPAA) |
May 13, 2009 |
| Attorney-Representatives Certification Of Form C-3 Or C-7 |
March 19, 2009 |
| Health Insurers Request For Reimbursement |
January 21, 2009 |
| Affidavit Of Exemption - Proof Of WC Coverage For 1-2-3-4 Family Owner-Occupied Residence |
December 6, 2008 |
| Statement On Specific Issues In Dispute For Controverted And Expedited Cases |
October 15, 2008 |
| Continuation To Carrier-Employer Billing Portion Of Forms C-4 C-4.2 C-4.3 C-5 PS-4 Or OT-PT-4 |
September 22, 2008 |
| Empoloyer Fraud Referral Form |
July 15, 2008 |
| Claimants Request For Further Action |
April 2, 2008 |
| Carriers Or Employers Request For Further Action |
March 12, 2008 |
| Cover Sheet-List Of Itemized Medical Bills In Controverted World Trade Center Case |
July 24, 2007 |
| Carriers Request For Benefit Increase Reimbursement (ยง 51) |
July 24, 2007 |
| Notice That You May Be Responsible For Medical Costs |
March 20, 2007 |
| Notice Of Election To Bring Partners Members Or Self Employed Persons Under Coverage Of NYS WC Law |
March 20, 2007 |
| Notice Of Right To Select Workers Compensation Board Authorized Health Care Provider |
March 20, 2007 |
| Carriers Request For Reimbursement Of Compensation Payments Under Section 15-8 (Yellow Paper) |
March 20, 2007 |
| Notice Of Satisfaction Of WC Lien From Third Party Recovery |
November 3, 2006 |
| Claim For Reimbursement Of Excess Benefits Paid Under Welfare Pension Or Benefit Plan |
November 3, 2006 |
| Assigment To Chair WCB Of Cause Of Action Against Health Care Provider |
October 23, 2006 |
| Licensed Representatives Disclosure Of Conflict Of Interest To Client |
October 23, 2006 |
| Revocation Of Election Of Not For Profit Corp Or Unincorporated Assoc To Exclude Unsalaried Executive Officer From WC Coverage |
May 2, 2006 |
| Revocation Of Election Of Municipal Corporation Or Other Political Subdivision To Bring Executive Officers Under WC Coverage |
May 2, 2006 |
| Revocation Of Election Of Corporation To Exclude Sole Shareholder Or Executive Officers From WC Coverage |
May 2, 2006 |
| Notice To Chair Of Withdrawal Of Request For Arbitration |
May 2, 2006 |
| Notice Of Election Of Not For Profit Corp Or Unincorporated Assoc To Execlude Unsalaried Executive Officer From WC Coverage |
May 2, 2006 |
| Notice Of Election Of Municipal Corporation Or Other Polictical Subdivision To Bring Executive Officers Under WC Coverage |
May 2, 2006 |
| Notice Of Election Of Corporation To Exclude Sole Shareholder Officer Or Executive Officers Shareholders From WC Coverage |
May 2, 2006 |
| Biannual Recertification To Entitlement To Benefits |
May 2, 2006 |
| Claimants Authorization To Disclose Health Information (Pursuant To HIPAA) |
May 2, 2006 |
| Direct Deposit Of Benefit Authorization Form |
April 27, 2006 |
| Request For Access To Claims E-Biz Application |
January 21, 2006 |
| World Trade Center Volunteers Claim For Compensation |
April 20, 2004 |
| Employers Application For Voluntary Coverage For Employees For Whom Disability Benefits Not Required (No Employee Contribution) |
April 15, 2004 |
| Affidavit Of Death Benefits (For Dependent Parents Or Grandparents) |
April 12, 2004 |
| Affidavit For Death Benefits (For Dependent Brothers Sisters Or Grandchildren) |
April 12, 2004 |
| Employers Application For Voluntary Coverage For Employees For Whom Disability Benefits Not Required (Employee Contribution) |
March 16, 2004 |
| Notice Of Termination Of Employers Participation In Self-Insured Association Union Or Trustees Plan |
June 26, 2003 |
| Tables Of Statutory Employee Contributions Disability Benefits Law |
January 14, 2002 |
| Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper) |
January 14, 2002 |
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