New York > Workers Compensation
Notice To Chair Of Carriers Action On Claim For Benefits C-669 - New York
| Notice To Chair Of Carriers Action On Claim For Benefits Form. This is a New York form and can be used in Workers Compensation . |
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PRINT CARRIER NAME HERE PRINT CARRIER NAME HERE NOTICE TO CHAIR OF CARRIER'S ACTION ON CLAIM FOR BENEFITS CHECK TYPE OF CASE: WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER ANSWER ALL QUESTIONS FULLY - TYPEWRITER OR COMPUTER PREPARATION IS REQUIRED ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. WCB Case Number 2. Carrier Case Number Name 3. Carrier Code 4. Date of Injury 5. Social Security Number Address to which notices should be sent 6. Injured Person 7. Employer* 8. Carrier *In volunteer firefighters' and volunteer ambulance workers' cases, enter the liable political subdivision (or unaffiliated ambulance service as defined in VAWBL) as the EMPLOYER 9. Description (Diagnosis) of injury 10. Place where injury occurred (city/county/state) 11. Date disability began..... 12. Date employer or carrier first had knowledge of injury, whichever is earlier.... 13. Date of receipt by carrier of employer's report of injury (C-2, VF-2 or VAW-2) (If none, so state)....................................................... 14. Date returned to work (if applicable).................................................................................................................................................... Complete items 1 and 2 below if either 15-A or 15-B is checked. 15. A. B. CLAIM IS NOT DISPUTED. PAYMENT HAS BEGUN. TEMPORARY PAYMENT OF COMPENSATION AND PRESCRIBED MEDICINE HAS BEGUN WITHOUT PREJUDICE AND WITHOUT ADMITTING LIABILITY (Sec. 21-a WCL) at a weekly rate of $ Date first payment mailed 1. Payment has begun from Check here if weekly rate shown is a temporary rate subject to adjustment upon receipt of payroll information and complete section 2 below. If the rate is less than the maximum in effect on the date of the injury (WCL 15, subd. 6(a)), the basis for the computation MUST be entered in item 2 and supporting documents (payroll or other) MUST be attached. 2. Basis For Computation - Workers' Compensation Cases Only Average Daily Wage $________________ x _________________ = $ _______________________________ -:- 52 = Average Weekly Wage $_______ x 2/3 = Weekly Comp. Rate (Subject to Maximum) If temporary rate indicate basis_______________________________________ Check here if payment made without prejudice, as provided in Sec.50 VFBL/VAWBL, pending determination of political subdivision/vol. ambulance service liable for benefits Death Cases: attach list of payees, showing name and address, relationship to deceased, date of birth, percentage of award and rate per week for each payee, if known. Also include name and address of undertaker, amount of funeral bill, amount of funeral bill paid and by whom (name and address). 16. a. b. c. d. e. f. CLAIM IS NOT DISPUTED. PAYMENT HAS NOT BEGUN FOR FOLLOWING REASON(S): No lost time beyond 7 days. (In volunteer firefighters' and ambulance workers' cases, 7 day waiting period does not apply.) Lost time exceeds 7 days, no medical evidence indicating disability beyond 7 days. (When such evidence is available, carrier must commence payment.) Possible schedule loss or disfigurement, but no loss of time from work at regular wages beyond 7 days. Lost time exceeds 7 days, but full wages being paid by employer during disability. Employer requests reimbursement in the amount of $______________ for the period Death case awaiting information as to dependents, if any, or dependency proofs - accidental death not controverted. Other to 17. 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. ____________________________ The insurance company will notify the Chair, Workers' Compensation Board, and the claimant and his/her representative, if any, if benefits are stopped or modified, or of any other change in the above information. Prepared by Official Title Compensation Board C-669 () Workers'New York State of Prescribed by Chair Dated Telephone No. & Extension SEE IMPORTANT INFORMATION TO CLAIMANT AND CARRIER ON REVERSE. American LegalNet, Inc. www.FormsWorkFlow.com This notice must be filed with the CHAIR, Workers' Compensation Board, by the Insurance Company or Self-Insured Employer at the office of the district in which the injury occurred. IF PAYMENT (INCLUDING TEMPORARY PAYMENT WITHOUT PREJUDICE) HAS BEGUN, this form must be filed on or before the 18th day after disability, or within 10 days after the employer first had knowledge of the injury, whichever period is greater. IF PAYMENT HAS NOT BEGUN, this form must be filed no later than 25 days after the Board has mailed the notice of indexing of a case. A copy of this notice must also be mailed to the CLAIMANT, to his or her REPRESENTATIVE, if any, and to ALL HEALTH PROVIDERS treating the claimant, at the same time it is filed with the Chair. TO THE CLAIMANT This notice shows that your employer or its insurance company has either: a. If Item 15-A is checked -- started to pay benefits to you without waiting for an award by the Workers' Compensation Board, or b. If Item 15-B is checked -- started to pay temporary benefits to you without admitting liability for your claim. or c. If Item 16 is checked -- does not now dispute the injury described on the other side of this form, but has not begun to pay benefits for the reasons shown. IF PAYMENT HAS BEGUN (Item 15-A), payment of benefits will be made to you, generally every two weeks, at the rate shown on the other side of this notice. Payments will continue until your employer or its insurance company notifies you and the Board, on Form C-8/8.6, that such payments are being stopped or modified for reasons which will be stated on the form. The Board will then notify you in writing of any further action taken in your claim. In order to avoid delays in payment, the insurance carrier may sometimes use a temporary compensation rate until payroll information is obtained from the employer. Later, when the proper rate is established, prior payments may have to be adjusted. The weekly rate at which payments are made is always reviewed by the Board. IF TEMPORARY PAYMENT HAS BEGUN (Item 15-B), payments may continue for up to one year or until your employer or its insurance company notifies you and the Board, on Form C-8/8.6, that such payments are being stopped. The Board will then notify you in writing of any further action taken in your claim. This payment is not an admission o
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