Modification Of Previous Report (ADR Program)
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Modification Of Previous Report (ADR Program) Form. This is a New York form and can be use in Workers Compensation.
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Tags: Modification Of Previous Report (ADR Program), ADR-1.1, New York Workers Compensation,
DOWNSTATE CENTRALIZED MAILING
(for New York City, Hempstead, Hauppauge & Peekskill Districts)
PO Box 5205 Binghamton, NY 13902-5205
100 Broadway State Office Building
Menands
44 Hawley Street
ALBANY 12241 BINGHAMTON 13901
NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 (866) 750-5157
(866) 802-3604
295 Main Street
935 James St.
Suite 400
130 Main Street W.
BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203
(866) 211-0645
(866) 802-3730
(866) 211-0644
State of New York - Workers' Compensation Board
Fax: 877-533-0337
www.wcb.state.ny.us
Alternative Dispute Resolution Program
Modification of Previous Report
Complete the identifying information and use the narrative portion to modify, clarify or update
information reported on any previously-filed ADR form.
INJURED EMPLOYEE (First Name, Middle Initial, Last Name)
DATE OF INJURY
EMPLOYEE'S ADDRESS (Street No. & Name, Apt. No, City, State and Zip Code)
WCB CASE NUMBER
UNION NAME & LOCAL NUMBER
EMPLOYER'S NAME AND MAILING ADDRESS
FILING ENTITY:
Employer
Carrier
INSURANCE CARRIER'S NAME AND MAILING ADDRESS
Other (If "Other", give name and address.)
CARRIER CASE NUMBER
CARRIER ID NUMBER
WNARRATIVE
Prepared by
Official Title
Date of this Report
Telephone Number & Extension
ADR-1.1 (1-11)
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
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