New York > Workers Compensation
Volunteer Ambulance Workers Claim For Benefits VAW-3 - New York
| Volunteer Ambulance Workers Claim For Benefits 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 VOLUNTEER AMBULANCE WORKER'S CLAIM FOR BENEFITS Does this claim involve disease or malfunction of the heart or of one or more coronary arteries? (Check one) W.C.B. CASE NO. (if known) CARRIER CASE NO. (if known) CARRIER CODE NO. Yes DATE OF INJURY No SEE REVERSE FOR FILING INSTRUCTIONS SOCIAL SECURITY NO. First Name Middle Initial Last Name Address (Give Number and Street, City, State, Zip Code) Apt. No. 1. VOLUNTEER AMBULANCE WORKER 2. AMBULANCE COMPANY 3. POLITICAL SUBDIVISION 4. (a) Marital Status_______________ (b) Sex_________ (c) Date of Birth__________________ (e) Tel. No. ( )__________________ INFORMATION, REGULAR WORK 5. Describe in detail your duties in regular employment______________________________________________________________________ ________________________________________________________________________________________________________________ 6. Your work week at time of injury was (check one) 5 days 6 days 7 days Other_________________________ _______________________________________________________________________________________________________________ 7. Employer's name and address_______________________________________________________________________________________ 8. (a) Were you injured in the line of duty in the jurisdiction of your own ambulance district or political subdivision? Yes No INJURY (b) If you were injured in the line of duty involving assistance call from another locality, give name of other ambulance district or political subdivision________________________________________________________________________________________________ 9. Address where injury occurred_______________________________________________________________________________________ _______________________________________________________________________________County__________________________ at_________________________o'clock________M 10. Date of injury___________________________________________________________ PLACE AND TIME 11. State full nature and cause of injury____________________________________________________________________________________ ________________________________________________________________________________________________________________ NATURE AND EXTENT OF INJURY ________________________________________________________________________________________________________________ 12. Has injury resulted in amputation? Yes No If yes, describe____________________________________________________ ________________________________________________________________________________________________________________ 13. On what date did you stop work because of this injury?___________________________________________________________________ 14. Have you returned to work? Yes Yes Yes No If yes, give date_________________________________________________________ No (b) Have you done any work during your disability? No (b) Are you now receiving medical care? No 15. (a) Does injury keep you from work? 16. (a) Did you receive medical care? Yes Yes No No MEDICAL CARE 17. (a) Are you now in need of medical care? Yes (b) Name and address of attending doctor______________________ _________________________________________________________________________________________________________________ 18. If you were treated in a hospital, give name and address___________________________________________________________________ _________________________________________________________________________________________________________________ VOLUNTEER AMBULANCE WORKERS' BENEFITS 19. Have you received volunteer ambulance workers' benefits payments for the injury reported above? 20. Are you now receiving volunteer ambulance workers' benefits payments? 21. Do you claim further volunteer ambulance workers' benefits payments? Yes Yes No No Yes No If yes, explain_______________________ ________________________________________________________________________________________________________________ 22. Have you given Notice to Liable Pol. Subdivision of Vol. Ambulance Worker's Injury or Death (Form VAW-1) to the political subdivision liable for the payment of your vol. ambulance workers' benefits? Yes No No If yes, was such Notice delivered personally? NOTICE Yes No or sent by Registered Mail? Yes If yes, to whom was Notice delivered/sent ___________________ ______________________________________________________________________________________Date______________________ Name of Officer and Political Subdivision ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO, OR BY AN INSURER, OR SELF INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. I certify that copy of this was filed with______________________________________________________________________________________________________ Name of Officer Political Subdivision or Ambulance Service Liable for Benefits Title of Officer _________________________________________________________________________ n__________________________________________________________ o Dated______________________________________ Signed by_____________________________________________________________or Volunteer Ambulance Worker Signed________________________________________________________________________________________________________________________________ A person on his/her behalf, or in case of death, by any one or more of his/her dependents, or person on their behalf. Relationship Telephone No. American LegalNet, Inc. www.FormsWorkFlow.com VAW-3 (1-11) THIS CLAIM SHOULD BE FILED WITH THE CHAIR, WORKERS' COMPENSATION BOARD, AS SOON AS POSSIBLE AFTER INJURY IS INCURRED. DO NOT DELAY FILING THIS CLAIM. WHAT EVERY VOLUNTEER AMBULANCE WORKER SHOULD KNOW IN CASE OF INJURY IN LINE OF DUTY A. The law requires every county, city, town, village or ambulance district to: 1. Provide Volunteer Ambulance Workers' Benefits in case of accident or injury in the line of duty. 2. Post a notice of compliance:(a) Giving the name of the insurance carrier, if the community is insured, or (b) Stating that the community is self-insured. (Look for this notice at your ambulance company headquarters. Advise the Workers' Compensation Board if it is not posted in a conspicuous place. Note: Ambulance Services unaffiliated with a politi
|
|||||||
