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Registration Of Participation In World Trade Center Rescue Recovery Clean-Up Operations WTC-12 - New York
| Registration Of Participation In World Trade Center Rescue Recovery Clean-Up Operations 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 REGISTRATION OF PARTICIPATION IN WORLD TRADE CENTER RESCUE, RECOVERY AND/OR CLEAN-UP OPERATIONS (Sworn Statement Pursuant to Workers' Compensation Law §162) Please read the background and instructions below completely and carefully before completing the Sworn Statement beginning on page 3. BACKGROUND 1. On August 14, 2006, Workers' Compensation Law (WCL) Article 8-A was enacted to expand the time for a "participant" in World Trade Center rescue, recovery and/or clean-up operations who suffers, or may suffer in the future, from a "qualifying condition" to file a claim for workers' compensation lost wage and medical benefits and to permit the Board to reopen such claims previously denied as untimely. 2. A "Participant in World Trade Center rescue, recovery, or cleanup operations" (referred to as "participant") is defined in WCL §161(1) as any: (a) employee who within the course of employment, or (b) volunteer upon presentation to the Board of evidence satisfactory to the Board that he or she: (i) participated in the rescue, recovery, or cleanup operations at the World Trade Center site between September 11, 2001 and September 12, 2002, or (ii) worked at the Fresh Kills Land Fill in New York City between September 11, 2001 and September 12, 2002, or (iii) worked at the New York City morgue or the temporary morgue on pier locations on the west side of Manhattan between September 11, 2001 and September 12, 2002, or (iv) worked on the barges between the west side of Manhattan and the Fresh Kills Land Fill in New York City between September 11, 2001 and September 12, 2002. 3. "World Trade Center site" is defined as "anywhere below a line starting from the Hudson River and Canal Street; east on Canal Street to Pike Street; south on Pike Street to the East River; and extending to the lower tip of Manhattan." 4. A "qualifying condition" is defined as "any latent disease or condition resulting from a hazardous exposure during participation in World Trade Center rescue, recovery or clean-up operations." 5. In order for the claim of a participant in World Trade Center rescue, recovery or cleanup operations to come within the application of Article 8-A of the Workers' Compensation Law, the participant is required to register with the Workers' Compensation Board ("Board"). The registration form (WTC-12) must be filed not later than September 11, 2010. 6. To register, this Sworn Statement must be accurately and truthfully completed and the original filed with the Board District Office or Downstate Central Mailing Center (see addresses below) not later than September 11, 2010. INSTRUCTIONS A. If you were a "participant" in World Trade Center rescue, recovery, and/or cleanup operations, as that term is defined above, you are required to provide information requested by the Board in the accompanying Sworn Statement if you were exposed to hazardous conditions which cause you to suffer, or may cause you to suffer in the future, from a "qualifying condition" for which you will or may file or have filed a claim for workers' compensation benefits. B. Please complete the Sworn Statement by providing the following information: Item 1. - Give your current residential address, including apartment number (if applicable), street number, street name, city, state and zip code. Give mailing address if different from the residential address provided. Be sure to include your telephone number. Please provide your Social Security Number and your date of birth by month/date/year. Item 2. - This sentence just states that you participated in the World Trade Center rescue, recovery and cleanup operations between September 11, 2001, and September 12, 2002, at the World Trade Center site, the Fresh Kills Land Fill, the New York City morgue or temporary morgue, or the barges between the west side of Manhattan and the Fresh Kills Land Fill. Item 3 - State whether you participated in the World Trade Center rescue, recovery and/or clean-up operations as an employee (in the course of your employment for pay) or as a volunteer (not in the course of your employment, but upon your own initiative without pay); WTC-12 (1-11) -1American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.state.ny.us Statewide Fax Line: 877-533-0337 Item 4 - List with a brief description any evidence of your activities as a volunteer, for example, badge, letters, statements, pictures, accommodations, etc.; Item 5 - Fill in the table. Specify the dates and locations of your participation in World Trade Center rescue, recovery and/or cleanup operations to the best of your ability. Describe the work you performed at each location on the date or dates you were there. Give the complete name and address of your employer (s) or the rescue entity/volunteer agency you volunteered with during the period of participation in World Trade Center rescue, recovery and/or clean-up operations, and if applicable and you know, the name of your employer's insurance carrier; and Item 6 - Indicate whether you previously filed a workers' compensation claim with the Board relating to your participation in World Trade Center rescue, recovery and/or cleanup operations. If you have, you must include the date the claim was filed and the WCB case number. Item 7 - This item states your understanding that filing the Sworn Statement, and thereby registering as a "participant," is not the same as filing a claim for workers' compensation benefits. To file a claim for benefits you must timely submit to the Board Form C-3 or Form WTCVol-3. Item 8 - This item states that you understand that the law penalizes those who submit false written documents to the Board and for making false statements. C. After you complete the Sworn Statement, please review it to insure that it is truthful and accurate. D. Sign the Sworn Statement in front of a notary public. Your signature on the Sworn Statement must be notarized or the comparable process for the jurisdiction in which you are located when signing this Statement. Do not sign the Sworn Statement until you are in the presence of the notary public. PLEASE NOTE: by signing this statement, you swear and affirm that the information provided and statements made therein are true under the penalty of perjury. You are also stating that you understand that the law prescribes penalties for perjury, for willfully making false statements in connection with an insurance claim, and for submitting a false instrument for
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