|
 New
York Worker's Compensation
Automated
Forms Package includes everything you need:
A-9
Agreement to Pay
Medical Costs in the Event of Failure to Prosecute or if Claim is Disallowed
ADR-1
Report of Work-Related Injury or
Occupational Disease
ADR-2
Alternative
Dispute Resolution Program Final Disposition of Claim
C-2
Employer’s
Report of Work-Related Accident/Occupational Disease
C-3
Employee’s Claim for
Compensation
C-3.1
Notice of Consent to Utilize an Employer/Carrier
Recommend Network or Health Care
Provider
C-4
Attending
Doctor’s Report and Carrier/Employer Billing Form
C-5
Attending
Ophthalmologist's Rep.
C-7
Notice that Right to
Compensation is Controverted
C-8.1
Notice of Treatment Issue(s)/Disputed Bill Issue(s)
C-8/8.6
Notice
that Payment of Compensation has been Stopped or Modified
C-11
Employer’s
Report of Change in Employment Status
C-21
Application for Lump Sum Payment
C-22
Application for Approval of Non-schedule Adjustment
C-22b
Request to Suspend or Reduce Payment of
Compensation
C-25
Application
for Reopening Claim More Than 7 Years After Accident
C-27
Medical Proof of Change in Condition in Support of Application for Reopening of Claim
C-32
Settlement Agreement
C-62
Claim for
Compensation in Death Case
C-64
Proof of Death
C-65
Proof of Burial and Funeral Expenses by Undertaker
C-89.3
Request for Priority Hearing
C-121
Claim for
Compensation and Notice of Commencement of Third Party Action
C-121.2
Notice of Satisfaction of Worker’s
Compensation Lien from Third Party Recovery
C-220
Notice of Issuance of New Policy or Reinstatement
C-221
Notice of Cancellation or Intention Not to Renew
C-240
Employer’s Statement of Wage Earnings
C-250
Notice of Claim for
Reimbursement out of the Special Disability Fund
C-251
Carrier’s Request for Reimbursement of
Compensation Payments under Section 15-8
C-251.1
Carrier’s
Request for Reimbursement of Medical Expenses
C-251.2
Carrier’s
Request for Reimbursement of Compensation Payments under Section 14-6
C-251.3
Notice of Right to
Reimbursement of Compensation Payments
C-256
Claim for Reimbursement of Excess
Benefits
C-256.1
NYS Employee’s
Retirement System Claim for Reimbursement
C-256.2
Claim for
Reimbursement of Wages to State Employee
C-257
Claimants Record of
Medical and Travel Expenses
C-300.5
Stipulation
C-300.34
Statement of Unresolved Issues - Special Part
C-370
Assignment to Chairman, Action against Physician
C-430S
Statement of Rights
C-669
Notice to Chair
of Carrier’s Action on Claim for Benefits
CB-8
Request for Conciliation
DB-271S
Statement of Rights – Disability Benefits Law
DB-300
Notice and Proof of Claim for Disability
Benefits
DB-450
Notice and Proof of Claim for Disability
Benefits
DB-451
Notice of
Total or Partial Rejection of Claim for Disability Benefits
DB-455
Notice of Disability
Benefits Payment
DB-470
Preliminary/Final Claim for Reimbursement
DB-850
Application
for Acceptance of Insurance Form
DC-120
Discharge or Discrimination Complaint
EC-32.1
Claimant Release for
Section 32 Waiver Agreement
HP-1
Health
Provider’s Request for Decision on Unpaid Medical Bill(s)
HP-4
Notice to Chair Worker’s
Compensation Board Withdrawal of Request for Arbitration
IME-3
Practitioner’s
Report of Request for Information/Response to Request Regarding Independent
Medical Exam
IME-4
Practitioner’s
Report of Independent Medical Exam
IME-5
Claimant’s Notice of
Independent Medical Exam
IME-7
Statement of Registration
MD-1
Attending
Doctor's Request for Medical Authorization Determination
MD-3
Carrier/Self-Insured
Employer's Objection to Order of the Chair Authorizing Special
Services
MD-4
Carrier/Self-Insured
Employer's Objection to Board's Affirmance of Order of the Chair
Authorizing Special Services
MR/IME-1
Health Provider’s Application for Authorization Under the W.C. Law
OC-110A
Claimant’s
Authorization to Disclose W.C. Records
OC-110A.1
Section 110-a Affirmation/Affidavit
OC-400
Notice of Retainer and Appearance/Notice of Substitution and Appearance
OC-400.1
Application for a Fee by Claimant’s
Attorney or Representative
OC-406
Notice of Retainer & Appearance on
Behalf of Employer
OC-408
Disclosure of Conflict of Interest to Client
OT/PT-4
Occupational/Physical Therapist’s
Report
PH-16.2
Pre-Hearing Conference Statement
PS-4
Attending Psychologist’s
Report
R
Carrier’s
Report on Rehabilitation
RB-89
Application for Board Review – Cover Sheet
RB-89.1
Rebuttal of
Application for Board Review Cover Sheet
RB-679
Notice to Chair of Carrier’s Action on Application for Reopening
RF-25
Request for Photocopies of Hospital Records
RFA-1
Claimant's
Request for Further Action
RFA-2
Carrier's
Request for Further Action
VAW-1
Notice to Liable Political Subdivision or Unaffiliated Ambulance Service of
Volunteer Ambulance Worker’s Injury or Death
VAW-2
Political Subdivision’s
Report of Injury to Volunteer Ambulance Worker
VAW-3
Volunteer Ambulance Worker’s Claim for Benefits
VAW-62
Claim for
Volunteer Ambulance Worker’s Benefits in Death Case
VF-1
Notice to Liable Political Subdivision of Volunteer Firefighter’s Injury or Death
VF-2
Political Subdivision’s
Report of Injury to Volunteer Firefighter
VF-3
Volunteer Firefighter’s Claim for Benefits
VF-62
Claim for
Volunteer Firefighter’s Benefits in Death Case
Our
software development team is continually working to improve and
enhance our automated forms packages. If you are aware of a form
that would make a positive addition to the above list, we'd love to
hear about it! Please call us toll-free or email
the information.
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