Notice Of Right To Reimbursement Of Compensation Payments
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Notice Of Right To Reimbursement Of Compensation Payments Form. This is a New York form and can be use in Workers Compensation.
Tags: Notice Of Right To Reimbursement Of Compensation Payments, C-251.3, New York Workers Compensation,
PRINT CARRIER NAME AND ADDRESS HERE
PRINT CARRIER NAME AND ADDRESS HERE
NOTICE OF RIGHT TO REIMBURSEMENT OF COMPENSATION PAYMENTS
UNDER SECTION 14 (6) AND SECTION 15 (8)
W.C.B. CASE NO.
CLAIMANT
CARRIER CASE NO.
CARRIER CODE
CLAIMANT'S SOC. SEC. NO.
CONCURRENT EMPLOYER
DATE OF ACCIDENT
EMPLOYER
CONCURRENT EMPLOYER'S ADDRESS
The claimant herein claims to have been concurrently engaged in more than one covered
employment at the time of injury. As a representative of the employer in whose employment
the claimant was injured we assert our right to file this Notice of Right to Reimbursement of
Compensation Payments in accordance with Section 14 (6) and Section 15 (8) of the
Workers' Compensation Law.
Prepared By
Date
Title
Tel. No.
INSTRUCTIONS:
Prepare this form in triplicate (three copies) and file as follows:
1. Original to the Claims Section in the office of the Workers' Compensation Board where the case is
pending (see District Office addresses below). Notice must be filed prior to the decision making an award or
your right to reimbursement may be deemed waived.
2. Forward one copy to Workers' Compensation Board, 20 Park Street, Albany,
New York 12207, ATT: FINANCE OFFICE.
3. Retain one copy for your files.
DOWNSTATE CENTRALIZED MAILING
(for New York City, Hempstead, Hauppauge & Peekskill Districts)
PO Box 5205 Binghamton, NY 13902-5205
NYC (800)877-1373/ Hemp. (866)805-3630/ Haup. (866)681-5354/ Peek. (866)746-0552
C-251.3 (1-11)
100 Broadway
Menands
ALBANY 12241
(866) 750-5157
State Office Building
295 Main Street
44 Hawley Street
Suite 400
130 Main Street W.
BINGHAMTON 13901 BUFFALO 14203 ROCHESTER 14614
(866) 802-3604
(866) 211-0644
(866) 211-0645
Statewide Fax Line: 877-533-0337
935 James St.
SYRACUSE 13203
(866) 802-3730
www.wcb.state.ny.us
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