[ IN PRINT NAME OF CARRIER OR SELF-INSURED EMPLOYER 24 POINT SIZE TYPE WITHIN BRACKETED SPACE ] NOTICE OF CLAIM FOR REIMBURSEMENT OUT OF THE SPECIAL DISABILITY FUND UNDER SECTION 15, SUBD. 8 ANSWER ALL QUESTIONS FULLY ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. CASE NUMBER 2. CARRIER CASE NUMBER 3. CARRIER CODE 4. DATE OF INJURY 5. SOCIAL SECURITY NUMBER NAM E 6. INJURED PERSON 7. EMPLOYER 8. CARRIER ADDRESS Apt. No. The carrier on behalf of the above-named employer is requesting apportionment of any liability that may be awarded for compensation or medical expenses on this claim and an order directing reimbursement pursuant to Workers' Compensation Law, Section 15 (8). The following information is furnished in support of this notice and claim, subject to further development of the record: 9. Previous physical impairment(s): Nature and Extent___________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________________________________Date of onset:____________________ 10. Subject of WC Claim: No Yes If yes, provide particulars (WCB Case No., Name of Employer, Carrier ) Subject of Court Action: No Yes If yes, provide particulars (e.g., Date, Court, Index No.) 11. Details of present claim: Form C-2 filed on: ___________________ Claimant's Date of Birth: _____________________ A.W.W. ____________________ Description of Injury:___________________________________________________________________________________________ ___________________________________________________________________________________________________________ If death, provide date of death: ______________ Nature of injury which caused the death:___________________________________ ___________________________________________________________________________________________________________ Compensation has been paid from __________ to __________. Payments are are not continuing. By________________________________ _____________________________ __________________ Name Title Date (____)__________________ Telephone No. For all claims, mail the original and one copy of this form and a check in the amount of $250 for each claim, payable to 'Special Disability Fund' to: WCB Finance Office, 20 Park St. Room 301, Albany, NY 12207. For multiple claims by one entity, one check may be submitted to pay the $250 filing fee for each claim. However, a spreadsheet with the claimant name, WCB case number and check number for each claim must be submitted. Failure to submit the filing fee for each claim will result in the return of this form to the carrier address listed above. THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. MAIL THIS FORM TO THE WORKERS' COMPENSATION BOARD C-250 (3-07) Prescribed by Chair Workers' Compensation Board State of New York www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkflow.com