New York > Workers Compensation
Request For Assistance By Injured Worker RFA-1W - New York
| Request For Assistance By Injured Worker Form. This is a New York form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
STATE OF NEW YORK - WORKERS' COMPENSATION BOARD REQUEST FOR ASSISTANCE BY INJURED WORKER This form is not to be used to report an injury. To file a claim, use Form C-3. WCB Case No.(if known) MM Date of Injury DD YY Your Name Your Address Check if new address: Employer's Name Employer's Address (if known) REASON FOR THIS REQUEST INSTRUCTIONS: Check all boxes that apply. Be sure to attach additional forms, medical reports, letters, etc. as required for each checkbox. If the additional information was already submitted do not attach it, but try to identify it in the space at the bottom of this form** by giving the form number or title and the date it was submitted to the Board. Sign and date the form below. Compensation Payments: a. I am not working as of ______________________ and not receiving payments. SHOWS A MEDICAL DISABILITY. ATTACH MEDICAL REPORT THAT b. My payments have been stopped or reduced. c. I have returned to work as of __________________ at full pay. d. I am making less money than I was before I got hurt. DOCTOR. ATTACH CURRENT PAY STUB AND MEDICAL REPORTS FROM YOUR ATTACH WEEKLY GROSS PAY ATTACH MEDICAL e. I had two or more employers on the date of accident/injury (concurrent employment). BEFORE YOUR INJURY AND STATEMENT FROM SECOND EMPLOYER REGARDING TIME LOST. REPORT THAT SHOWS A MEDICAL DISABILITY AND RELEASE FROM CUSTODY PAPERS. f. I was released from incarceration on ____________________ and am not receiving payments. g. I have not been paid as directed in the decision filed on _____________________. Medical Issues: h. My request for medical treatment was denied or has not been addressed. i. My disability is now permanent. Check this box if you were under 25 years of age at time of accident. ATTACH DENIAL LETTER. ATTACH MEDICAL FORM C-4.3, DOCTOR'S REPORT OF MMI/PERMANENT IMPAIRMENT j. My medical condition has changed. RECEIPTS AND FORM C-257. ATTACH MEDICAL FORMS. ATTACH k. My request for medical and transportation reimbursement was denied or has not been addressed. Other Issues: l. I have new information and/or information requested by the Board regarding ____________________________ _________________________________________________________________________________________ ATTACH DOCUMENTS. m. Other (Explain fully in the space provided below.) **Document reference information (date, name/title,form ID):_________________________________________________________________ Injured Worker's Signature:________________________________________ Date:_______________ Telephone No.:_________________ This form and any attachments must be mailed, faxed or e-mailed to the Workers' Compensation Board. (See mailing and email filing addresses on the reverse side.) RFA-1W (1-11) SEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO American LegalNet, Inc. www.FormsWorkFlow.com To the Claimant - General Information On Using This Form You may file this form (RFA-1W) with the Workers' Compensation Board when you want the Board to take a specific action in your claim, or if you need to alert the Board to any problem or situation that is affecting your claim. Many of the most frequently requested actions/situations are listed as either compensation payment issues (items a through g), or medical issues (items h through k), but you are not limited to those listed. Check all that apply and/or add additional information or explanation in the space provided (l or m). Complete the identifying information at the top of Form RFA-1W and send the form, WITH ALL APPLICABLE INFORMATION ATTACHED*, to your local Workers' Compensation Board district office (see addresses below) or the Downstate Centralized Mailing P.O. Box if your local district office is in New York City, Hempstead, Hauppauge or Peekskill. The Board will contact you and all parties when it takes action on your claim. *After each checkbox you will see the information needed in bold capital letters. For example, if you are letting the Board know that your disability is now permanent (box i), the information required is Form C-4.3, Doctor's Report of MMI/Permanent Impairment. YOU MUST SEND A COPY OF THIS FORM TO THE INSURANCE CARRIER(S), OR DIRECTLY TO THE EMPLOYER OR ITS THIRD PARTY ADMINISTRATOR IF THE EMPLOYER IS SELF-INSURED. If you have any other concerns, you may contact the Board's ADVOCATE FOR INJURED WORKERS at 1-800-580-6665. Additional information about other Board services may be obtained at the Board's website: WWW.WCB.STATE.NY.US. If you would like to follow your claim on-line, you can register for eCase using the registration instructions available on the Board's website under the eCase link. You have the right to legal representation. A lawyer cannot charge you directly for representation in a workers' compensation claim. If there is an award in your claim, any legal fee request must be approved by the Board and will be deducted from the award to you by the insurance carrier and paid directly to the lawyer. Para el reclamante: información general sobre el uso del presente formulario Puede presentar este formulario (RFA-1W) ante la Junta de Compensación Obrera en caso de que desee que la WCB tome una medida específica respecto de su reclamo, o si necesita alertar a la WCB sobre cualquier problema o situación que afecta su reclamo. Muchas de las acciones/situaciones requeridas con más frecuencia se enumeran como asuntos relacionados con pagos de indemnizaciones (puntos a al g) o asuntos médicos (puntos h al k); sin embargo usted no está limitado sólo a esos puntos. Marque todos aquéllos que correspondan y/o agregue información adicional o explicaciones en el espacio previsto para tal fin (l o m). Complete la información de identificación en la parte superior del formulario RFA-1W y envíelo, ADJUNTANDO TODA LA INFORMACIÓN QUE CORRESPONDA*, a la oficina distrital de su WCB (ver las direcciones a continuación) o a la casilla postal de Downstate Centralized Mailing si su oficinal distrital se encuentra en la ciudad de Nueva York, Hempstead, Hauppauge o Peekskill. La WCB se comunicará con usted y todas las partes cuando trate su reclamo. *A continuación de cada casilla de verificación verá la información necesaria en letras mayúsculas en negrita. Por ejemplo, si está informando a la WCB que su incapacidad ahora es permanente (recuadro i), la información requerida es el Formulario C-4.3, Informe del médico sobre Máxima mejoría médica/Incapacidad Permanente. DEBE ENVIAR UNA COPIA DE ESTE FORMULARIO A LA
|
|||||||
