New York > Workers Compensation
Modification Of Previous Report (ADR Program) ADR-1.1 - New York
| Modification Of Previous Report (ADR Program) Form. This is a New York form and can be used in Workers Compensation . |
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100 Broadway State Office Building Menands 44 Hawley Street ALBANY 12241 BINGHAMTON 13901 NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 (866) 750-5157 (866) 802-3604 DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 295 Main Street 935 James St. Suite 400 130 Main Street W. BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203 (866) 211-0645 (866) 802-3730 (866) 211-0644 Fax: 877-533-0337 State of New York - Workers' Compensation Board www.wcb.state.ny.us Alternative Dispute Resolution Program Modification of Previous Report Complete the identifying information and use the narrative portion to modify, clarify or update information reported on any previously-filed ADR form. INJURED EMPLOYEE (First Name, Middle Initial, Last Name) EMPLOYEE'S ADDRESS (Street No. & Name, Apt. No, City, State and Zip Code) DATE OF INJURY WCB CASE NUMBER UNION NAME & LOCAL NUMBER INSURANCE CARRIER'S NAME AND MAILING ADDRESS EMPLOYER'S NAME AND MAILING ADDRESS FILING ENTITY: Employer Carrier Other (If "Other", give name and address.) CARRIER CASE NUMBER CARRIER ID NUMBER WNARRATIVE Prepared by Date of this Report Official Title Telephone Number & Extension ADR-1.1 (1-11) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. American LegalNet, Inc. www.FormsWorkFlow.com
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