New York > Workers Compensation
Application For Reopening Of Claim More Than Seven Years After Accident C-25 - New York
| Application For Reopening Of Claim More Than Seven Years After Accident Form. This is a New York form and can be used in Workers Compensation . |
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295 Main Street 100 Broadway State Office Building Suite 400 Menands 44 Hawley Street 130 Main Street W. 935 James St. 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) 211-0645 (866) 802-3604 (866) 211-0644 (866) 802-3730 DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 Statewide Fax Line: 877-533-0337 STATE OF NEW YORK WORKERS' COMPENSATION BOARD APPLICATION FOR REOPENING OF CLAIM, MORE THAN SEVEN YEARS AFTER ACCIDENT AND THIS AGENCY EMPLOYS SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. NOTICE: This form must be filed immediately with the Chair, Workers' Compensation Board, together with attending doctor's report (Form C-27) if required, at the district office where the case was closed. Information on reverse side must be completed. ANSWER ALL QUESTIONS FULLY - PRINT OR TYPE CLEARLY Claimant's W.C.B. Case No. __________________ Date of Accident _________________ Social Security No. _________________ 1. Name of injured ___________________________________________ Sex _________ Date of Birth_______________ Present address____________________________________________________________________ Apt. No. _______ 2. Employer (at time of accident) _______________________________________________________________________ Address ________________________________________________________________________________________ 3. When did you last work for this employer? ______________________________________________________________ 4. Name of present attending doctor _____________________________________________________________________ Address _________________________________________________________________________________________ 5. If injured employee is deceased, give date of death _______________________________________________________ 6. Nature of injury ____________________________________________________________________________________ 7. State specific reasons why you desire reopening of your case _______________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 8. RECORD OF MEDICAL TREATMENT SINCE THE ACCIDENT (List all doctors and hospitals): Doctor or Hospital Address ____________________________ ____________________________ ____________________________ _____________________________ _____________________________ _____________________________ Period From ____________ To ____________ From ____________ To ____________ From ____________ To ____________ Yes No 9. Were you originally provided with any apparatus or appliances for your injury or furnished with treatment at the time of the accident? .......................................................................................... (a) If "Yes," who provided and paid for it? ________________________________________________ (b) Has such apparatus been replaced or repaired? ............................................................................ (c) If "Yes," by whom and on what date? _________________________________________________ _______________________________________________________________________________ 10. Has any medical or surgical treatment or hospital care been furnished to you by employer or insurance carrier within the last 8 years? ..................................................................... 11. Has apparatu sor artificial appliance been furnished or repaired by employer or insurance carrier within the last 8 years? ......................................................................................... 12. Did you sue anyone other than filing for compensation as a result of your accident?............................. If "Yes," provide the following: Yes No Yes Yes Yes No No No Name and address of attorney ___________________________________________________________ Date settled__________________________ Amount of Settlement: $____________________________ Submit copy of settlement papers, if available. (Complete the information on the reverse side) C-25 (1-11) C-25 C-25 C-25 C-25 C-25 C-25 American LegalNet, Inc. www.FormsWorkFlow.com 13. Has any compensation been paid to you within the past 8 years?...................................................... If "Yes," give the following information: Yes No (a) When was last payment made?___________________________________________________ (b) By whom? ____________________________________________________________________ (c) Were you given lighter duties?.................................................................................................... (d) If Yes to (c), were benefits received for reduced earnings?.......................................................... 14. Have you sustained any other injury since the closing of your case?.................................................. If "Yes," state the following: Yes Yes Yes No No No (a) Nature of such injury ___________________________________________________________ (b) Date of accident _______________________________________________________________ (c) Name of the employer __________________________________________________________ (d) W.C.B. Case Number __________________________________________________________ (e) Last date of hearing ____________________________________________________________ 15. Are you currently working?................................................................................................................. Yes Yes No No If you are not currently working, are you retired?................................................................................ If you are currently working, give the following information: (a) Name of latest employer ________________________________________________________ Address _____________________________________________________________________ Employer's NYS U.I.Registration No. (if known) ______________________________________ (b) When did present period of disability begin? _________________________________________ (Date) (c) Give first and last date you worked on the job immediately preceding present disability: First day worked _______________________ Last day worked ________________________ Yes No (d) Are you receiving disability benefits for your present
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