Ny wcb form a-9661 pdf

Third party administrators workers compensation forms. New york is one of a handful of states that require employers to provide disability benefits coverage. Penalties for not having coverage ny construction payroll limitation employer whistleblower form public contracts. Request for administrative award nys workers compensation board po box 5205 binghamton, ny 9025205 request for arbitration nys workers compensation board, medical directors office riverview center, suite 195, 150 broadway menands, ny 12204. New york workers compensation board releases model policy. Employee claim form c3 workers compensation board ny. Discharge or discrimination complaint dc120 pdf fpdf. See detailed instructions and time limits on forms. Individuals seeking to serve legal papers on the board should file their papers with the office of the secretary at 328 state street, schenectady, ny 12305. Attached is an application for a certificate of attestation of exemption from new york state workers compensation andor disability benefits insurance coverage. Workers compensation board shall cover only those employees that are eligible for benefits under. The two mandatory sections of this form are part a claim.

You can demonstrate attachment in one or more ways. Employees claim for compensation filed by the employee when making a claim within two years of injuryillness, or within two years after employee knew or should have known that injury or illness was related to employment c3. Commonly used forms available for printing and mailing to the workers. Discharge or discrimination complaint dc 120 this is a new york form that can be used for workers compensation. Commonly used forms available for printing and mailing to the workers compensation board. For the period of disability covered by this claim are you. Wcb case number if you know it fill out this form to apply for workers compensation benefits because of a work injury.

You may file a paper form by printing the employee claim c3 adobe pdf form, or by visiting any workers compensation board office. Special funds group 328 state street, room 331 schenectady, ny 12305. Nys workers compensation board centralized mailing po box 5205 binghamton, ny 9025205 vdf1 112. Notice of right to select a workers compensation board authorized health care provider completed by. Information for employersbusinesses workers compensation board. Centralized mailing address for all workers compensation claims and claimrelated documents.