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 American LegalNet, Inc. www.FormsWorkFlow.com