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Political Subdivisions Report Of Injury To Volunteer Firefighter VF-2 - New York
| Political Subdivisions Report Of Injury To Volunteer Firefighter Form. This is a New York form and can be used in Workers Compensation . |
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STATE OF NEW YORK-WORKERS' COMPENSATION BOARD POLITICAL SUBDIVISION'S REPORT OF INJURY TO VOLUNTEER FIREFIGHTER Send this Report directly to Chair, Workers' Compensation Board at address shown on reverse side within ten (10) days after injury is incurred. Answer all questions fully. Copy also should be provided to or retained by your insurance carrier. Any political subdivision that fails to timely file Form VF-2, as required by Section 110 of the Workers' Compensation Law and Section 42 of the Volunteer Firefighters' Benefit Law, shall be subject to a fine of not more than $1,000. In addition, the Board or Chair may impose a penalty of up to $2,500. TYPEWRITER PREPARATION IS STRONGLY RECOMMENDED - INCLUDE ZIP CODE IN ALL ADDRESSES-VOLUNTEER FIREFIGHTER'S S.S.NO. MUST BE ENTERED BELOW WCB CASE NO.(If Known) CARRIER CASE NO. CARRIER CODE NO. VF POLICY NO. SOCIAL SECURITY NO. WNAME ADDRESS 1. POLITICAL SUBDIVISION OR FIRE DISTRICT 2. FIRE COMPANY 3. INSURANCE CARRIER IF ANY 4.NAME AND ADDRESS OF VOLUNTEER FIREFIGHTER I N J U R E D P E R S O N 5.(a) SEX 5.(b) DATE OF BIRTH month 6.NAME AND ADDRESS OF REGULAR EMPLOYER day year 7. HAS INJURED FIREFIGHTER RETURNED TO REGULAR EMPLOYMENT Yes No 8. WHERE DID INJURY OCCUR? (Specify in building, outside building, en route in fire truck, etc.) 9. CHECK ONE: THE ABOVE-NAMED VOLUNTEER FIREFIGHTER WAS INJURED IN THE LINE OF DUTY WHILE SERVING WITH HIS/HER OWN FIRE COMPANY OR FIRE DEPARTMENT. 11. DATE DISABILITY BEGAN THE ABOVE-NAMED VOLUNTEER FIREFIGHTER, MEMBER OF ANOTHER FIRE DEPARTMENT, WAS INJURED IN LINE OF DUTY AFTER HIS/HER SERVICES HAD BEEN ACCEPTED BY THE ABOVE-NAMED FIRE COMPANY OR FIRE DEPARTMENT. 12. DATE OF FIRST KNOWLEDGE OF INJURY 13. WAS NOTICE OF INJURY GIVEN IN WRITING Yes No 10. DATE OF INJURY I N J U R Y 14. ADDRESS WHERE INJURY OCCURRED 15. NAMES AND ADDRESSES OF WITNESSES (Attach separate sheet if necessary.) 16. NATURE OF INJURY AND PART(S) OF BODY AFFECTED: (e.g., "INJURY TO CHEST", etc.) 17. DID YOU PROVIDE MEDICAL CARE? IF YES, WHEN (b) NAME AND ADDRESS OF HOSPITAL Ye No 18. (a) NAME AND ADDRESS OF DOCTOR 19. WHAT WAS FIREFIGHTER DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material firefighter was using.) C A U S E O F I N J U R Y 20. HOW DID THE INJURY OR EXPOSURE OCCUR? (Please describe fully the events that resulted in injury or occupational disease. Tell what happened and how it happened. Please use separate sheet if necessary.) 21. (a) WAS PROTECTIVE EQUIPMENT PROVIDED. (Such as gas mask, etc.) (c) WAS PROTECTIVE EQUIPMENT DEFECTIVE? Yes No (b) WAS PROTECTIVE EQUIPMENT IN USE AT THE TIME? Yes No Yes No IF YES, IN WHAT WAY (Attach separate sheet if necessary). FATAL CASES 22. (a) DATE OF DEATH (b) NAME AND ADDRESS OF NEAREST RELATIVE (c) RELATIONSHIP DATE OF THIS REPORT P R E P A R A T I O N IF FORM IS SUBMITTED BY POLITICAL SUBDIVISION, COMPLETE A & B BELOW. IF FORM IS SUBMITTED BY THIRD PARTY, COMPLETE A,B,C & D BELOW. B. TITLE TELEPHONE NUMBER & EXTENSION A. PERSON PREPARING FORM OR SUPPLYING INFORMATION TO THIRD PARTY C. IF REPORT PREPARED BY THIRD PARTY, COMPANY NAME AND ADDRESS D. THIRD PARTY CONTACT NAME TELEPHONE NUMBER & EXTENSION VF-2 (1-11) VF-2 VF-2 VF-2 VF-2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO POLITICAL SUBDIVISIONS: reports should be sent directly to the district offices at these addresses: ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all incidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all incidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all incidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all incidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all incidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 eek. (866) 746-0552 For all incidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. LIABILITY FOR BENEFITS AND DUTY TO COMPLETE AND FILE THIS REPORT - VOLUNTEER FIREFIGHTERS' BENEFIT LAW Section 42. Reports of injuries, claims and proceedings. If an injury is one for which an insurance carrier might be liable under a contract of insurance or a county plan of self-insurance might be required to pay, the officer to whom a notice of injury is required to be delivered or mailed and with whom the claim in relation to such injury is required to be filed under the provisions of this chapter shall send a copy of such notice and claim and a copy of any notice of a proceeding relating to an injury or claim to such insurance carrier or county plan of self-insurance, as the case may be, promptly after receiving the same. The political subdivision liable for the payment of benefits under this chapter shall keep such records and make such reports to the chair of the workers' compensation board as required by article seven, section one hundred ten, of the workers' compensation law, which by section fifty-seven of this chapter is made applicable to this chapter. Failure to comply with the provision of this section shall not relieve such an insurance carrier of liability or a county plan of self-insurance from its obligation to pay. (See below excerpt of Article 7, Section 110, of the Workers' Compensation Law). Section 50. Payments pending controversies. In order that the benefits to be paid and provided under this chapter shall be paid promptly where such benefits are conceded to be due to any person because of the death of or injuries to a volunteer firefighter, but controversy exists as to which political subdivision is liable for the payment thereof, the municipal corporations and fire districts involved in such controversy and their insuran
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