New York > Workers Compensation
Notice That Right To Compensation Is Controverted C-7 - New York
| Notice That Right To Compensation Is Controverted Form. This is a New York form and can be used in Workers Compensation . |
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Notice That Right To Compensation Is Controverted State of New York - Workers' Compensation Board C-7 PRINT CARRIER NAME HERE Check type of case: WCB Case Number: Carrier Case Number: Workers' Compensation Volunteer Firefighter Volunteer Ambulance Worker Date of Alleged Injury/Illness: ________/________/________ Carrier Code No.: W A. Claimant Information & Contentions 1. Claimant: First M.I. Last Social Security Number: Mailing Address: Number and Street City State Zip Code 2. Where did alleged injury/illness happen? (e.g., 1 Main Street, Troy, at the front door) 3. How did alleged injury/illness happen? (e.g., claimant tripped over a pipe and fell on the floor) 4. Claimant's Doctor: Address: Number and Street City State Zip Code 5. Description (diagnosis) of alleged injury/illness: 6. Date alleged disability began: ________/________/________ 7. Was alleged injury the result of the use or operation of a motor vehicle? If yes, give name and address of motor vehicle insurance carrier: Yes No License plate number: B. Employer Information 1. Employer:* Address: Number and Street City State Zip Code 2. Carrier: Address: Number and Street City State Zip Code 3. Date of employer's first knowledge of alleged injury/llness: ____/____/____ Date carrier received C-2/VF-2/VAW-2: _____/_____/_____ 4. Name of Disability Benefits Carrier: Address: Number and Street City State Zip Code 5. Date DB Carrier notified of controversy and provided a copy of medical reports as required by 12 NYCRR 363.12: _____/_____/_____ * In volunteer firefighters and volunteer ambulance workers' benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in Sec. 30 VAWBL) is deemed to be "Employer." THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION American LegalNet, Inc. www.FormsWorkFlow.com C-7.0 (1-11) Page 1 of 2 www.wcb.state.ny.us C. Issues Raised and Factual Basis for Controverting Claim (check all raised - see instructions on Page 4) Prima Facie Medical Evidence Accident within meaning of Workers' Compensation Law Accident Arising Out Of and In the Course of Employment Occupational Disease within meaning of Workers' Compensation Law Occupational Disease Arising Out Of and In the Course of Employment Notice (Section 18) Notice (Section 45) Employer-Employee Relationship 1. Specify the legal and/or factual basis which support the issue(s) raised above. Causally Related Accident or Occupational Disease Causally Related Death Proper Employer Entity Cancellation of Coverage Proper Carrier Subject Matter Jurisdiction Timely Filing (Section 28) 2. List all documents which will be used to support the issue(s) raised above. Within the Board's file (give name and ID number): Within the possession of the insurer but not in the Board's file (list and describe all documents): 3. List all witnesses (name, and if known, address and telephone number) which may be used to support the issue(s) raised above along with the information he/she/they will provide: D. Certification By signing in the spaces provided below, I certify that to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances that the allegations and other factual matters asserted in controverting the claim or the defenses asserted have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigation or discovery. Further, this Notice That Right to Compensation is Controverted is being filed under the following provision (check only one): Workers' Compensation Law Sec. 25(2)(a) Volunteer Ambulance Workers' Benefit Law, Section 50 Volunteer Firefighters' Benefit Law, Section 50 Workers' Compensation Law Sec. 25(2)(b) Workers' Compensation Law Sec. 21-a Signature of Person Preparing Form: Print Name: Carrier's Legal Representative: Print Name: Title: Title: Date: _____/_____/_____ Date: _____/_____/_____ Designated carrier employee (see NYCRR 325-1.4) who receives requests for authorization of special medical services costing more than $1,000: Name: _____________________________________________________________ Telephone No.: (________)__________________________ C-7.0 (1-11) Page 2 of 2 www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com Filing of Notice of Controversy This notice must be filed by the carrier or employer with the Chair, Workers' Compensation Board, on or before the 18th day after disability or within 10 days after the employer first had knowledge of the alleged injury, whichever period is greater. In the event that the Board sends a notice of indexing to the employer or the insurance carrier indicating that the Board has jurisdiction over the claim for compensation, the employer or carrier must file this form within 25 days, or risk a waiver of pleading certain defenses to the claim. If the initial certification is not signed by a legal representative, then before a legal representative may appear on behalf of the insurance carrier, the legal representative shall file and serve the required certification. A copy of this notice, including these instructions, must also be mailed to the claimant, to his or her representative, if any, and to all health care providers treating the claimant simultaneously with its filing with the chair. As required by 12 NYCRR 363.12, a copy of this notice with medical report(s), if any, must also be furnished promptly to the disability benefits carrier. Further Proceedings on this Controverted Claim for Compensation The following procedure applies: 1. Pre-Hearing Conference: If the Board's file contains a medical report referencing an injury, the Board shall conduct a pre-hearing conference within thirty days of receipt of this notice. Parties must comply with all rules, regulations, and statutes regarding the pre-hearing conference. Pre-Hearing Conference Statement: The Board directs the parties, except a claimant who has not retained a legal representative, to serve upon all parties of 2. interest, and file with the Board, a pre-hearing conference statement no later than ten days before the date of the pre-hearing conference. If the claimant retains a legal representative ten days or more prior to the conduct of the pre-hearing conference, a pre-hearing conference statement must be served upon all parties of interest, and filed with the Board. 3. Orders and Directions: If the claim warrants further proceedings be
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