VOLUNTEER AMBULANCE WORKER'S CLAIM FOR BENEFITS Does this claim involve disease or malfunction of the heart or of one or more coronary arteries? (Check one) W.C.B. CASE NO. (if known) CARRIER CASE NO. (if known) CARRIER CODE NO. Yes No SEE REVERSE FOR FILING INSTRUCTIONS SOCIAL SECURITY NO. DATE OF INJURY First Name Middle Initial Last Name Address (Give Number and Street, City, State, Zip Code) Apt. No. 1. VOLUNTEER AMBULANCE WORKER 2. AMBULANCE COMPANY 3. POLITICAL SUBDIVISION 4. (a) Marital Status (b) Sex (c) Date of Birth (e) Tel. No. ( ) INFORMATION, REGULAR WORK 5. Describe in detail your duties in regular employment 6. Your work week at time of injury was (check one) 7. Employer's name and address 8. (a) Were you injured in the line of duty in the jurisdiction of your own ambulance district or political subdivision? Yes No 5 days 6 days 7 days Other INJURY (b) If you were injured in the line of duty involving assistance call from another locality, give name of other ambulance district or political subdivision 9. Address where injury occurred PLACE AND TIME County 10. Date of injury 11. State full nature and cause of injury at o'clock M NATURE AND EXTENT OF INJURY 12. Has injury resulted in amputation? Yes No If yes, describe 13. On what date did you stop work because of this injury? 14. Have you returned to work? Yes No Yes Yes If yes, give date No No Yes No (b) Have you done any work during your disability? (b) Are you now receiving medical care? Yes Yes No No 15. (a) Does injury keep you from work? 16. (a) Did you receive medical care? MEDICAL CARE 17. (a) Are you now in need of medical care? (b) Name and address of attending doctor 18. If you were treated in a hospital, give name and address VOLUNTEER AMBULANCE WORKERS' BENEFITS 19. Have you received volunteer ambulance workers' benefits payments for the injury reported above? 20. Are you now receiving volunteer ambulance workers' benefits payments? 21. Do you claim further volunteer ambulance workers' benefits payments? Yes Yes No No Yes No If yes, explain 22. Have you given Notice to Liable Pol. Subdivision of Vol. Ambulance Worker's Injury or Death (Form VAW-1) to the political subdivision Yes No liable for the payment of your vol. ambulance workers' benefits? If yes, was such Notice delivered personally? NOTICE Yes No or sent by Registered Mail? Yes No If yes, to whom was Notice delivered/sent Date Name of Officer and Political Subdivision ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO, OR BY AN INSURER, OR SELF INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. I certify that copy of this was filed with Name of Officer Political Subdivision or Ambulance Service Liable for Benefits Title of Officer _________________________________________________________________________ n__________________________________________________________ o Dated______________________________________ Signed A person on his/her behalf, or in case of death, by any one or more of his/her dependents, or person on their behalf. Relationship Telephone No. Signed by_____________________________________________________________or Volunteer Ambulance Worker VAW-3 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com THIS CLAIM SHOULD BE FILED WITH THE CHAIR, WORKERS' COMPENSATION BOARD, AS SOON AS POSSIBLE AFTER INJURY IS INCURRED. DO NOT DELAY FILING THIS CLAIM. WHAT EVERY VOLUNTEER AMBULANCE WORKER SHOULD KNOW IN CASE OF INJURY IN LINE OF DUTY A. The law requires every county, city, town, village or ambulance district to: 1. Provide Volunteer Ambulance Workers' Benefits in case of accident or injury in the line of duty. 2. Post a notice of compliance:(a) Giving the name of the insurance carrier, if the community is insured, or (b) Stating that the community is self-insured. (Look for this notice at your ambulance company headquarters. Advise the Workers' Compensation Board if it is not posted in a conspicuous place. Note: Ambulance Services unaffiliated with a political subdivision are not required to provide coverage under the VAWBL. However, if coverage is provided, a notice of compliance must be posted.) B. What You Must Do 1. You must give written notice of injury on Form VAW-1 or this Form VAW-3 by the designated officer of the political subdivision liable for benefits as follows: If the political subdivision liable for benefits is a a. County b. City c. Town d. Village e. Ambulance District personal delivery or registered mail WITHIN NINETY DAYS after injury to Then deliver to Clerk of Board of Supervisors Comptroller or Chief Financial Officer Town Clerk Village Clerk Secretary a. b. c. d. e. 2. 3. 4. 5. If a political subdivision is not liable for benefits, file this form with the head of the unaffiliated ambulance service. The home county, city, town, village or ambulance district is liable for the payment of benefits, regardless of whether service was rendered for the home area or for another area under contract or in response to a call for assistance. Form VAW-1 is only a notice of injury or death and not a claim for benefits. In order to claim benefits, you must file this Form VAW-3 no later than two years after injury with: (a) Chair, Workers' Compensation Board (see address below) and (b) The same officer to whom a notice of injury was sent (item B1 above). If you file Form VAW-3 WITHIN NINETY DAYS, it serves as both a notice of injury and a claim for benefits, and you do not need to file Form VAW-1. You should secure medical attention promptly (see item 2 below regarding choice of doctor). Attend the hearing on your case if you are notified to appear before the Workers' Compensation Board. Go back to work as soon as you are able. C. Your Rights 1. As a volunteer ambulance worker, you are entitled to benefits if you suffer injury in the line of duty. 2. Generally, you are entitled to be treated by a doctor of your choice, provided he/she is authorized by the Board. If the ambulance service or political subdivision is involved in a preferred provider organization (PPO) arrangement, you must obtain initial treatment from the certified preferred provider organization which has been designated to provide health care services for volunteer ambulance workers' injuries. 3. You are entitled to be paid for drugs, crutch