New York > Workers Compensation
Carriers Request For Benefit Increase Reimbursement (§ 51) VF-VAW-10 - New York
| Carriers Request For Benefit Increase Reimbursement (§ 51) 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 VF/VAW ADJUSTMENTS CARRIER'S REQUEST FOR BENEFIT INCREASE REIMBURSEMENT UNDER SECTION 51 VOLUNTEER FIREFIGHTERS' & VOLUNTEER AMBULANCE WORKERS' BENEFIT LAWS WCB Case No. Claimant Carrier: Carrier Address: Carrier Case No. Social Sec. No. Vol. Fire Claim Vol. Ambulance Claim Original weekly benefit rate in this claim: $_________ Increased benefit rate effective Jan. 1, 1999: $_________ Original weekly benefit rate in this claim: $_________ Increased benefit rate effective July 27, 2004: $_________ (VAW ONLY) Original weekly benefit rate in this claim: $_________ Increased benefit rate effective Jan. 2, 2006: $_________ The Carrier requests reimbursement for benefits paid, as follows: A. Compensation/Death Benefits Weeks from Weeks from Weeks from B. C. Lump Sum Re-marriage Award To To To at $ at $ at $ /wk /wk /wk $ $ $ $ $ $ ................................................................................................................ ................................................................................................................ TOTAL OF THIS CLAIM FOR REIMBURSEMENT 1. 2. Does this represent an initial request for reimbursement in this claim? Yes No If this is the initial request for reimbursement, or re-marriage award, you must attach the following: a. b. A copy of the Notice of Decision establishing the classification and benefit rate or award. A copy of Form C-8/8.6 verifying the rate change. CARRIER STATEMENT I hereby certify that this request for reimbursement made to the Chair of the Workers' Compensation Board is true and correct; that no part thereof has been previously paid and that the amount stated therein is due and owing. By (Print or Type): Signature: Title: Telephone No. Date: INSTRUCTIONS: 1. Claims for compensation reimbursement should be submitted for 52-week periods. 2. Forward original and one copy, along with any required documentation to: WORKERS' COMPENSATION BOARD FUND FOR REOPENED CASES UNIT - ROOM 312 20 PARK ST, ALBANY NY 12207 3. Retain one copy for your records. VF/VAW-10 (10-06) www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkflow.com
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