New York > Workers Compensation
ADR Program Final Disposition Of Claim ADR-2 - New York
| ADR Program Final Disposition Of Claim Form. This is a New York form and can be used in Workers Compensation . |
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100 Broadway State Office Building 295 Main Street Menands 44 Hawley Street 935 James St. Suite 400 130 Main Street W. ALBANY 12241 BINGHAMTON 13901 BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203 NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 (866) 750-5157 (866) 802-3604 (866) 211-0645 (866) 802-3730 (866) 211-0644 DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 Fax: 877-533-0337 State of New York - Workers' Compensation Board www.wcb.state.ny.us ALTERNATIVE DISPUTE RESOLUTION PROGRAM FINAL DISPOSITION OF CLAIM This form is to be filed with the Board within 30 days of final disposition or settlement of a claim. INJURED EMPLOYEE (First Name, Middle Initial, Last Name) EMPLOYEE'S ADDRESS ( Street No. & Name, Apt. No., City, State & Zip Code) UNION NAME & LOCAL NUMBER WCB CASE NUMBER DATE OF INJURY EMPLOYEE'S SOCIAL SECURITY NUMBER PART(S) OF BODY AFFECTED AND DIAGNOSIS - FOR DEATH CLAIMS, SO NOTE AND STATE CAUSE AVERAGE WEEKLY WAGE EMPLOYER'S NAME AND MAILING ADDRESS INSURANCE CARRIER'S NAME AND MAILING ADDRESS FILING ENTITY: Employer Carrier Other (If "Other", give name and address.) CARRIER ID NUMBER WCARRIER CASE NUMBER COMPENSATION PAYMENTS MADE: Periods of Payment From To Weekly Rate Amount WAS THIS CASE THE SUBJECT OF MEDIATION OR ARBITRATION? IF YES, ATTACH A COPY OF ANY WRITTEN DECISION. FINAL DISPOSITION: (CHECK ALL THAT APPLY) YES - MEDIATION YES - ARBITRATION NO CONTROVERTED CASE--CLAIM DENIED. DESCRIBE BASIS:____________________________________________________________________ SCHEDULE LOSS OF USE AWARD/DESCRIBE:_______________________________________________________________________________ PERMANENT PARTIAL DISABILITY CLASSIFICATION/DESCRIBE:________________________________________________________________ CLAIMANT RETURNED TO WORK. DATE OF RETURN:_____________________ SECTION 32 SETTLEMENT/ATTACH COPY OF AGREEMENT OTHER/EXPLAIN:________________________________________________________________________________________________________ Prepared by Official Title Date of this Report Telephone Number & Extension AT PRE-INJURY WAGES AT REDUCED WAGES ADR-2 (1-11) ADR-2 ADR-2 ADR-2 American LegalNet, Inc. www.FormsWorkFlow.com ADR-2 Prescribed by Chair Workers' Compensation Board State of New York SEE FILING INSTRUCTIONS ON REVERSE THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. FILING INSTRUCTIONS Form ADR-2, Final Disposition of Claim, must be filed with the Workers' Compensation Board for every case in which Form ADR-1, Alternative Form Dispute Resolution Program Report of Injury, was filed with the Board. ADR-2 must be filed within 30 days of the final resolution of a claim, as required by 12 NYCRR 314.7(a). A copy of any written mediation or Failure to arbitration decision regarding this claim is to be filed with this form. file the prescribed ADR forms with the Workers' Compensation Board in a timely manner may result in the assessment of one or more penalties and/or the revocation of the party's authorization to participate in the Alternative Dispute Resolution Pilot Program. ADR-2 Reverse (1-11) American LegalNet, Inc. www.FormsWorkFlow.com
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