STATE OF NEW YORK - WORKERS' COMPENSATION BOARD POLITICAL SUBDIVISION'S REPORT OF INJURY TO VOLUNTEER AMBULANCE WORKER Send this Report directly to Chair, Workers' Compensation Board at address shown on reverse side within ten (10) days after injury is incurred. Answer all questions fully. Copy also should be provided to or retained by your insurance carrier. Any political subdivision that fails to timely file Form VAW-2, as required by Section 110 of the Workers' Compensation Law and Section 42 of the Volunteer Ambulance Workers' Benefit Law, shall be subject to a fine of not more than $1,000. In addition, the Board or Chair may impose a penalty of up to $2,500. TYPEWRITER PREPARATION IS STRONGLY RECOMMENDED - INCLUDE ZIP CODE IN ALL ADDRESSES-VOLUNTEER AMBULANCE WORKER'S S.S.NO. MUST BE ENTERED WCB CASE NO.(If Known) CARRIER CASE NO. CARRIER CODE NO. VAW POLICY NO. SOCIAL SECURITY NO. WADDRESS NAME 1. POLITICAL SUBDIVISION OR AMBULANCE DISTRICT 2. AMBULANCE COMPANY 3. INSURANCE CARRIER IF ANY 5.(a) SEX 4.NAME AND ADDRESS OF VOLUNTEER AMBULANCE WORKER I N J U R E D P E R S O N 5.(b) DATE OF BIRTH month day year 7. HAS INJURED AMBULANCE WORKER RETURNED 6.NAME AND ADDRESS OF REGULAR EMPLOYER TO REGULAR EMPLOYMENT Yes No 8. WHERE DID INJURY OCCUR? (Specify in building, outside building, en route in ambulance, etc.) 9. CHECK ONE: 11. DATE DISABILITY BEGAN 10. DATE OF INJURY I N J U R Y THE ABOVE-NAMED VOLUNTEER, MEMBER OF ANOTHER AMBULANCE DEPARTMENT, WAS INJURED IN LINE OF DUTY AFTER HIS/HER SERVICES HAD BEEN ACCEPTED BY THE ABOVE-NAMED AMBULANCE COMPANY OR DEPARTMENT. THE ABOVE-NAMED VOLUNTEER AMBULANCE WORKER WAS INJURED IN THE LINE OF DUTY WHILE SERVING WITH HIS/HER OWN AMBULANCE COMPANY OR AMBULANCE DEPARTMENT. 12. DATE OF FIRST KNOWLEDGE OF INJURY 14. ADDRESS WHERE INJURY OCCURRED 13. WAS NOTICE OF INJURY GIVEN No Yes IN WRITING 15. NAMES AND ADDRESSES OF WITNESSES (Attach separate sheet if necessary.) 16. NATURE OF INJURY AND PART(S) OF BODY AFFECTED: (e.g., "INJURY TO CHEST", etc.) 17. DID YOU PROVIDE MEDICAL CARE? Yes No IF YES, WHEN (b) NAME AND ADDRESS OF HOSPITAL 18. (a) NAME AND ADDRESS OF DOCTOR 19. WHAT WAS AMBULANCE WORKER DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material ambulance worker was using.) C A U S E O F I N J U R Y FATAL 20. HOW DID THE INJURY OR EXPOSURE OCCUR? (Please describe fully the events that resulted in injury or occupational disease. Tell what happened and how it happened. Please use separate sheet if necessary.) Yes 21. (a) WAS PROTECTIVE EQUIPMENT PROVIDED. (Such as gas mask, etc.) (c) WAS PROTECTIVE EQUIPMENT DEFECTIVE? 22. (a) DATE OF DEATH Yes No No Yes (b) WAS PROTECTIVE EQUIPMENT IN USE AT THE TIME? No IF YES, IN WHAT WAY (Attach separate sheet if necessary.) (b) NAME AND ADDRESS OF NEAREST RELATIVE (c) RELATIONSHIP CASES DATE OF THIS REPORT P R E P A R A T I O N IF FORM IS SUBMITTED BY POLITICAL SUBDIVISION, COMPLETE A & B BELOW. IF FORM IS SUBMITTED BY THIRD PARTY, COMPLETE A,B,C & D BELOW. A. PERSON PREPARING FORM OR SUPPLYING INFORMATION TO THIRD PARTY B. TITLE TELEPHONE NUMBER & EXTENSION C. IF REPORT PREPARED BY THIRD PARTY, COMPANY NAME AND ADDRESS D. THIRD PARTY CONTACT NAME VAW-2 (1-11) TELEPHONE NUMBER & EXTENSION VAW-2 VAW-2 VAW-2 VAW-2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO POLITICAL SUBDIVISIONS AND UNAFFILIATED AMBULANCE SERVICES: reports should be sent Statewide Fax Line: 877-533-0337 directly to the district offices at these addresses: ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 Peek. (866) 746-0552 For all accidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. LIABILITY FOR BENEFITS AND DUTY TO COMPLETE AND FILE THIS REPORT - VOLUNTEER AMBULANCE WORKERS' LAW Section 42. Reports of injuries, claims and proceedings. If an injury is one for which an insurance carrier might be liable under a contract of insurance or a county plan of self-insurance might be required to pay, the officer to whom a notice of injury is required to be delivered or mailed and with whom the claim in relation to such injury is required to be filed under the provisions of this chapter shall send a copy of such notice and claim and a copy of any notice of a proceeding relating to an injury or claim to such insurance carrier or county plan of self-insurance, as the case may be, promptly after receiving the same. The political subdivision or volunteer ambulance company liable for the payment of benefits under this chapter shall keep such records and make such reports to the chair of the workers' compensation board as required by article seven, section one hundred ten, of the workers' compensation law, which by section fifty-seven of this chapter is made applicable to this chapter. Failure to comply with the provision of this section shall not relieve such an insurance carrier of liability or a county plan of self-insurance from its obligation to pay. (See below excerpt of Article 7, Section 110, of the Workers' Compensation Law). Section 50. Payments pending controversies. In order that the benefits to be paid and provided under this chapter shall be paid promptly where such benefits are conceded to be due to any person because of the death of or injuries to a volunteer ambulance worker, but controversy exists as to which political subdivision or volunteer ambulance company is liable for the payment thereof, the municipal corporations, volunteer ambulance companies and ambulance districts involved in such controversy and their insurance carriers, if any, may agree that any one or more of such municipal corporations or volunteer ambulance companies or ambulance districts or its insurance carrier shall pay or provide the benefits to, or in relation to, the person conceded to be entitled to such benefits without waiting for a final determination of the controversy, and may carry out the provisions of such an agreement. Notwithstanding any such payment, any party to the agreement may seek a final determination of the controversy in the same manner as if such benefits had not been paid or provided and any such payment or provision of benefits shall not prejudice any rights of the political subdivision or volunteer ambulance company or its insurance carrier paying or providing the same, nor be taken as an admission against interest. After a final determination the parties to the agreement shall make any necessary and proper reimbursement to conform to the determination. WORKERS' COMPENSATION LAW Section 110. Record and report of injuries by employers*. 1. An employer, or a third party designated by the employer, shall record any injury or illness incurred by one of its employees in the course of employment using the form prescribed by the chair for reporting injuries under subdivision two of this section. Such form, a copy of which shall be provided to the injured employee upon request, shall be maintained by the employer, or a third party designated by the employer, for at least eighteen years, and shall be subject to review by the chair at any time. Such form need not be filed with the chair unless the status of such injury or illness changes resulting in a loss of time from regular duties or in medical treatment which would require reporting in accordance with subdivision two of this section. 2. An employer, or a third party designated by the employer, shall file with the chair of the workers' compensation board and with the carrier if the employer is insured, upon a form prescribed by the chair, a report of any accident resulting in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid. Such report shall state the name and nature of the business of the employer, the location of its establishment or place of work, the name, address and occupation of the injured employee, the time, nature and cause of the injury and such other information as may be required by the chair. Such report shall be filed within ten days after the occurrence of the accident. An employer shall furnish a report of an occupational disease incurred by an employee in the course of his or her employment, to the chair of the workers' compensation board, and to the carrier if the employer is insured, upon the same form. The carrier, within fourteen days of receipt of the report or accompanying the initial check forwarded to the employee, whichever is earlier, or a self-insured employer, within fourteen days of transmitting the report to the chair or accompanying the initial check forwarded to the employee, whichever is earlier, shall provide the injured employee or, in the case of death, his or her dependents with a written statement of their rights under this chapter, in a form prescribed by the chair. An employer shall file a report of any other accident resulting in personal injury incurred by its employee in the course of employment, upon the same form, whenever directed by the chair. 3. Any injury or illness which is not required to be reported in accordance with subdivision two of this section, shall not be used as a basis for determining experience modification rates, provided the employer pays in the first instance or reimburses the employer's insurer for the treatment rendered to the employee. 4. An employer who refuses or neglects to make a report or to keep records as required by this section shall be guilty of a misdemeanor, punishable by a fine of not more than one thousand dollars. The board or chair may impose a penalty of not more than two thousand five hundred dollars upon an employer who refuses or neglects to make such report. 5. The chair shall be authorized to promulgate regulations necessary to carry out the provisions of this section. * In volunteer ambulance workers' benefit cases, the liable political subdivision or unaffiliated ambulance service is deemed to be the "employer" of the ambulance worker. THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. VAW-2 (1-11) Reverse www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com