COURT STATE OF NEW YORK COUNTY .OF. . . . . . . . . . . . . . . . .WORKERS' .COMPENSATION BOARD ......... .. ......... ............... : WORLD TRADE CENTER VOLUNTEER'S CLAIMIndex No. FOR COMPENSATION Calendar No. : JUDICIAL SUBPOENA IMPORTANTE: El Numero de su Seguro Social Debe Ser Indicado: Plaintiff(s) A. Injured person ANSWER ALL QUESTIONS FULLY - PRINT OR TYPE CLEARLY : IMPORTANT: Your Social Security Number Must Be Entered: 1. Name............................................................................................................................................................ First Name Middle Name Last Name -against- : 2. Mailing Address............................................................................................................................................. 3. Sex Male Female 4. Do you speak English? Yes Date of Birth..................................Telephone No. ( : No )............................ If no, what language do you speak?.................................................. : 1. Did a volunteer agency or a rescue entity direct you to go to Ground Zero or its vicinity or to the Staten Island B. Landfill ? Yes No If Yes, nameDefendant(s) entity............................................................................... of agency or : ...................................................... Place/Time 2. What date(s) were you volunteering at or near Ground Zero or the Staten Island Landfill: ................................... .................................................................................................................................................................... 3. Date of injury/illness.................................................... at .........................o'clock, AM PM THE PEOPLE OF THE STATE OF NEW YORK 1. How did injury/illness occur?........................................................................................................................... TO C. The Injury .................................................................................................................................................................... .................................................................................................................................................................... 2. Who was directing your activities at the time the injury/illness occurred? ........................................................... 3. What organization, if any, did the person directing your activities at the time of the injury/illness represent? ........ GREETINGS: .................................................................................................................................................................... WE COMMAND of your injury/illness, including all parts of laid injured...................................................... 1. State fully the nature YOU, that all business and excuses being bodyaside, you and each of you attend before , the Honorable at the Court .................................................................................................................................................................... D. located at County of Nature and in room.................................................................................................................................................................... , on the day of , 20 , at o'clock in the noon, and at any recessed Extent of 2. Did you stop testify and because of this a witness in Yes No If Yes, date or adjourned date, toregular workgive evidence as injury/illness?this action on the part of the stopped........................... Injury/ Illness 3. If you stopped regular work, have you returned to work? Yes No If Yes, date returned.......................... 4. Name of Regular Employer............................................................................................................................. 5. Addressfailure to comply with this subpoena is punishable as a contempt of court and will make you liable to Your of Regular Employer......................................................................................................................... the party on you received any benefits from the Crime Victim's Fund or any other $50 and duedamages sustained as a 1. Have whose behalf this subpoena was issued for a maximum penalty of agency all to your injury? result of your failure to comply. Yes No If Yes, amount: $............................. received from......................................................... 2. Did you receive or are you now receiving medical care? Witness, Honorable 3. Are you now in need of medical care? Court in County, day of E. Benefits/ Medical Care Yes No Yes No , one of the Justices of the , 20 4. Name of attending doctor................................................................................................................................ Doctor's address............................................................................................................................................ 5. If you were in a hospital, give the dates hospitalized......................................................................................... (Attorney must sign above and type name below) Name of hospital............................................................................................................................................ Hospital's Address.......................................................................................................................................... Attorney(s) for 6. Did you incur any out-of-pocket expenses for medical care to treat the injury/illness sustained? Yes No If Yes, what is the total amount of out-of-pocket expenses incurred? ................................................................. I hereby present my claim for compensation for injury/illness resulting from volunteer work at Ground Zero, and in support of it I make the foregoing statement of facts. Office and P.O. Address 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, 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. Telephone No.: Facsimile No.: (Claimant) Send completed form to: NYS Workers' Compensation Board, E-Mail Address: PO Box 5205, Binghamton, NY 13902-5205. Mobile Tel. No.: WTCVol-3 (2-04) SEE OTHER SIDE FOR IMPORTANT INFORMATION - VEASE AL DORSO PARA INFORMACION DE IMPORTANCIA Signed by......................................................................................................... Dated........................................................ American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : TO THE CLAIMANT The federal government has appropriated a grant to compensate volunteers injured or disabled while providing assistance to New Yorkers following the September 11, 2001 terrorist attack on the World Trade Center. These funds are known as the New York State World Trade Center Volunteer Plaintiff(s) Fund. The New York State Workers' Compensation Board will receive claims from volunteers suffering illness or injury resulting from volunteering -againstat the World Trade Center site or the Staten Island Landfill, and will administer payments from the fund in accordance with the Workers' Compensation Law and Board rules. By completing, signing and filing this form, you are making a claim against the NYS World Trade Center Volunteer Fund. Index No. AL RECLAMANTE El gobierno: federal ha reservado una partida para compensar voluntarios Calendar No. heridos o que hayan sufrido alguna lesión o incapacidad mientras asistían a las víctimas del ataque terrorista perpetrado contras las torres gemelas del World Trade Center. Este fondo ha sido identificado como el " Fondo para : los Voluntarios del World Trade Center". La Junta de Compensación Obrera del estado de Nueva York recibirá reclamaciones de voluntarios que hayan : sufrido heridas o lesiones como resultado de su trabajo voluntario en la tragedia del " World Trade Center" o en la Cantera de Staten Island, y realizará pagos del fondo bajo las regulaciones de la ley de Compensación : Obrera y los reglamentos de la Junta. Al completar, firmar y radicar esta forma usted estará iniciando una reclamación contra el "Fondo para Voluntarios del World Trade Center" en el estado de Nueva York. JUDICIAL SUBPOENA : Please note that benefits for all World Trade Center volunteers are limited to the continued existence of the funding provided through the World Trade Es importante entender que estos beneficios están supeditados a la Defendant(s) Center Volunteer Fund. continua existencia de los fondos previstos para el Fondo Voluntario del : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . World. Trade. Center. ... ... In order to document your claim, we ask that you keep the following documentation on hand pending notification from the Workers' Para justificar su reclamación le solicitamos que conserven los siquientes Compensation Board: documentos para cuando la Junta se los requiera: -Doctor and hospital reports THE PEOPLE OF THE STATE OF NEW YORK -Informes médicos y de hospital. -Cualquier recibo que no haya sido reembolsado, relacionado con cuidados medicos o con gastos incurridos tales como la transportación para visitas médicas y recibos de recetas compradas. -Any non-reimbursed receipts associated with medical care and "out-of-pocket" expenses such as mileage to and from doctors TO and prescription receipts. -If you are claiming wage replacement benefits, a record of earnings prior to September 11, 2001 will be required to calculate your average weekly wage upon which your benefit GREETINGS: Copies of pay stubs or income tax returns rate will be based. will be satisfactory. WE COMMAND YOU, pending claim with Please notify your health provider(s) that you have athat all business the World Trade Center Volunteer Fund administered by the Workers' the Honorable Compensation Board and that their bills and medical reports are to be located Unit, 100 County of sent to the Workers' Compensation Board, No Insurance at Broadway-Menands, Albany NY 12241. the in room , on day of -Si usted está reclamando beneficios por salarios dejados de recibir, se requerirá evidencia de ingresos anteriores al 11 de septiembre del 2001 para calcular el promedio de su ingreso semanal sobre los cuales se calcularán sus beneficios. Copias de cheques de nómina o copias de planilla de contribuciones serán suficientes. and excuses being laid aside, you and each of you attend before at theFavor de notificar a sus proveedores médicos que usted tiene una , Court reclamación pendiente en el "Fondo para Voluntarios del World Trade Center" administrado por la Junta de Compensación Obrera. Sus facturas e informes médicoso'clock in the deberán ser enviados a: Juntaand at any recessed , at noon, de Compensación Obrera, No Insurance Unit, 100 Broadway, Menands, Albany, NY 12241. , 20 or adjourned date, to testify and giveAuthorized health witness in this action on the part of the evidence as a be beneficial to seek treatment from a Board It may provider who will be familiar with the Board's practices regarding medical Sería aconsejable gestionar tratamiento médico con un proveedor autorizado reporting and billing. In addition, you should instruct health providers to por la Junta que conozca las normas en a los informes médicos y a los include your name and WCB Case Number on all bills and reports. (A métodos de facturación. También se debe requerir del proveedor médico que WCB case number will be assigned when your claim is received by the se incluya su nombre y número de caso WCB en todo informe o factura. [ Your failure to comply with this this injury Board.) You should not pay any of your medical bills relating to subpoena is punishable as a contempt of court andreclamación sea recibida en la un número WCB será asignado cuando su will make you liable to while your claim is on whose behalf this Board. Treating health the party being processed by the subpoena was issued for Junta] Usted no deberá pagar ninguna all damages sustained ascon a maximum penalty of $50 and factura médica relacionados a providers will be reimbursed in accordance with the New York State estos eventos mientras su reclamación esté radicada en la Junta. result of your failure to Workers’ Compensation Fee Schedule. comply. Notification Pursuant Witness, Honorable to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Court in County, day of Sec. 552a). The Workers’ Compensation Board’s (“Board”) authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers’ Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records. The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state and federal law. The Board’s Director of Operations, located at 100 Broadway, Menands, New York 12241 (518-474-6674), is primarily responsible for the maintenance of agency records containing personal claimant information. Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntary release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim. HIPAA Notice In order to adjudicate a claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information. WTCVol-3 (2-04) Reverse , Notificación conforme a la onede Protección de la of the , Ley of the Justices Privacidad de Nueva York [Ley de Servidores Públicos 6-A] y el Acta Federal de Privacidad de 1974 [5 U.S.C. 20 Sec.552a]. La autoridad de la Junta de Compensación Obrera para requerir información personal de los reclamantes surge de las Secciones 20 y 142 de la Ley de Compensación Obrera. Esta información se utiliza para ayudar a la Junta a procesar reclamaciones en forma eficiente y mantener expedientes precisos. (Attorney must sign celosamente la información confidencial de la La Junta guarda above and type name below) información personal que requiere. Esa información solo se comparte con personal de la Junta y sus agentes en relación al cumplimiento de sus deberes oficiales. Información personal recopilada por la Junta solo sera compartida con personas o entidades fuera de la Junta cuando sea requerido por leyes estatales o federales. Attorney(s) de Operaciones de la Junta con oficinas en 100 for El Director Broadway, Menands, New York 12241 [518-474-6674], es responsable directo del mantenimiento de los expedientes de la agencia que contienen información personal de los reclamantes. Si usted no suministra la información requerida en ésta forma, esto no quiere decir que su reclamación sera denegada, pero puede retrasar el procesamiento de su caso. El tener su seguro social permite a la Junta tomar Office todo lo concerniente acción rápida en and P.O. Addressa la información relacionada con su reclamación. Aviso de Telephone No.: HIPAA Como requisito para adjudicar una reclamación, la ley de compensación obrera WCL 13-a{4} {a} y 12No.: Facsimile NYCRR 325-1.3 requiere a los proveedores de salud radicar regularmente ante la Junta, el asegurador o el patrono informes sobre el tratamiento médico. Conforme a 45CFR 164.512 estos informes médicos E-Mail Address: requeridos por ley estan exentos de las restricciones sobre información médica impuestos por HIPAA. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com