New York > Workers Compensation
Volunteer Firefighters Claim For Benefits VF-3 - New York
| Volunteer Firefighters Claim For Benefits 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 VOLUNTEER FIREFIGHTER'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 FIREFIGHTER 2. FIRE COMPANY 3. POLITICAL SUBDIVISION LIABLE FOR BENEFITS 4. (a) Marital Status______________ (b) Sex_______ (c) Date of Birth____________________ (d) 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 fire 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 fire district or political subdivision _________________________________________________________________________________________________ 9. Address where injury occurred_____________________________________________________________________________________ ______________________________________________________________________________County__________________________ PLACE AND TIME 10. Date of injury_______________________________________________________________________at____________o'clock________M 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 17. (a) Are you now in need of medical care? Yes (b) Name and address of attending doctor_______________________ CARE ________________________________________________________________________________________________________________ 18. If you were treated in a hospital, give name and address___________________________________________________________________ ________________________________________________________________________________________________________________ 19. Have you received volunteer firefighters' benefits payments for the injury reported above? Yes No VOLUNTEER FIREFIGHTERS' BENEFITS 20. Are you now receiving volunteer firefighters' benefits payments? 21. Do you claim further volunteer firefighters' benefits payments? Yes Yes No No If yes, explain______________________________ _______________________________________________________________________________________________________________ 22. Have you given Notice to Liable Political Subdivision of Volunteer Firefighter's Injury or Death (Form VF-1) to the political subdivision NOTICE liable for the payment of your volunteer firefighters' benefits? Yes No or sent by Registered Mail? Yes Yes No No If yes, was such Notice delivered personally? 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 Liable for Benefits Title of Officer ___________________________________________________________________ on____________________________________________________________ Dated________________________________________ Signed by______________________________________________________or Volunteer Firefighter Relationship Telephone American LegalNet, Inc. www.FormsWorkFlow.com ( ) 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. VF-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 FIREFIGHTER SHOULD KNOW IN CASE OF INJURY IN LINE OF DUTY A. The law requires every county, city, town, village or fire district to: 1. Provide Volunteer Firefighters' 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 fire company headquarters. Advise the Workers' Compensation Board if it is not posted in a conspicuous place.) B. What You Must Do 1. You must give written notice of injury on Form VF-1 or this Form VF-3 by personal delivery or registered mail WITHIN NINETY DAYS after i
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