Site Navigation

WCB Home Page
Change Font Size
Glossary of WCB Terms

Workers' Compensation Forms for Injured Workers

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader Link to External Website which is available as a free download from Adobe's web site.

After the form opens in your browser, you may complete the form by typing information on the form before you print it.

IMPORTANT: Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.

If you require assistance with completing these forms, please contact your local WCB District Office.

Popular Forms

 

All Injured Workers Forms

Form Number /
Version Date
Form Title Who Files Where to File When to File
A-9 (1/07)
A-9S (Spanish version) on reverse
Notice that You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim is Disallowed, or if Agreement Pursuant to WCL §32 is Approved Employee File with Health Provider Health providers are permitted to obtain the claimant's agreement to pay usual and customary fees in the event claim is not prosecuted or is disallowed. Form should be retained by doctor after it is completed and signed.
A-9C (10/12) 关于在未提起诉讼、诉讼驳回或 WCL §32 项下协议获得批准的情况下需支付医疗费用的通知

A-9H (10/12)

SONJE OU KA RESPONSAB POU DEPANS MEDIKAL SIZOKA OU PA ALE NAN LAJISTIS, OSWA SI OU JWENN REFI POU REKLAMASYON KONPANSASYON, OSWA SI OU JWENN APWOBASYON POU AKÒ DAPRE SEKSYON 32 WCL

A-9I (10/12)

ATTENZIONE: LE SPESE MEDICHE POTREBBERO ESSERE RITENUTE A SUO CARICO IN CASO DI ABBANDONO O DI MANCATA APPROVAZIONE DELLA RICHIESTA DI INDENNIZZO O QUALORA SI APPROVI UN ACCORDO TRA LE PARTI SECONDO QUANTO STABILITO ALLA §32 DELLA WCL

A-9K (10/12)

WCB보상 청구를 수행하지 않거나 보상 청구가 각하되거나 또는 WCL §32에 따른 합의가 승인되는 경우 귀하는 의료비에 대한 책임이 있을 수 있습니다.

A-9P (10/12)

NINIEJSZYM ZWRACAMY UWAGĘ, ŻE W PRZYPADKU NIESKUTECZNEGO ZŁOŻENIA WNIOSKU, NIEUZNANIA ROSZCZENIA O ODSZKODOWANIE LUB W RAZIE ZATWIERDZENIA POROZUMIENIA ZGODNEGO Z §32 PRZEPISÓW DOTYCZĄCYCH ODSZKODOWAŃ ZA WYPADKI PRZY PRACY (WCL) OSOBA POSZKODOWANA MOŻE PONIEŚĆ KOSZTY USŁUG MEDYCZNYCH

A-9R (10/12) ИЗВЕЩЕНИЕ О ТОМ, ЧТО ВЫ МОЖЕТЕ НЕСТИ ОТВЕТСТВЕННОСТЬ ЗА РАСХОДЫ НА ЛЕЧЕНИЕ В СЛУЧАЕ НЕПРЕДЪЯВЛЕНИЯ ЗАЯВЛЕНИЯ ИЛИ ОТКЛОНЕНИЯ ЗАЯВЛЕНИЯ О КОМПЕНСАЦИИ ИЛИ ПРИ ОДОБРЕНИИ СОГЛАШЕНИЯ В СООТВЕТСТВИИ С §32 ЗАКОНА О КОМПЕНСАЦИЯХ РАБОТНИКАМ
AFF-1 (1-11) Affidavit For Death Benefits Claimant (see when to file) Workers' Compensation Board This affidavit is to be used by a surviving spouse or the dependent child(ren) of the deceased; by dependent brothers/sisters/grandchildren; by dependent parents/grandparents. It can also be used by the non-dependent parents or the estate of the deceased where there is no surviving spouse or other dependents.
AFF-2
(obsolete)
Affidavit For Death Benefits (Dependent Brothers/Sisters/Grandchildren) Form AFF-1 can now be used for all claims previously filed on forms AFF-2 and AFF-3
AFF-3
(obsolete)
Affidavit For Death Benefits (Dependent Parents/Grandparents) Form AFF-1 can now be used for all claims previously filed on forms AFF-2 and AFF-3
C-3 (1/11) Paper Version

[C-3 On-line Submission]

[C-3 Instructions]
Employee Claim Employee Workers' Compensation Board, in the event of on-the-job injury or illness. Within two years of accident, or within two years after employee knew or should have known that injury or illness was related to employment.
CLAIMANT INFORMATION PACKET
(which includes the two sided document, a C-3 form and C-3.3 form)

Compendio Información Reclamante (Claimant Information Packet, Spanish)
CLAIMANT INFORMATION PACKET
(which includes the two sided document, a C-3 form and C-3.3 form)
Employers or their designees, such as third-party administrators or insurance carriers. (Note: The Claimant Information Packet is not filed with the Board) Provided to an injured worker immediately after a work-related accident or exposure. When an employee is injured due to a work-related accident or becomes ill due to exposure, the employer or its designee must provide the injured worker with the Claimant Information Packet as soon as possible. The employer or its designee must note on the C-2 form that the packet was given to the injured worker.
C-3S (1/11) Reclamo del empleado Empleado Junta de Compensación Obrera, en la eventualidad de lesión en el trabajo ó enfermedad. Dentro del término de dos años del accidente, o dentro del término de dos años después que el empleado supo ó debió saber que la lesion o enfermedad estaba relacionada con el trabajo.
C-3C (10/12) 员工索赔
C-3H (10/12) Demann Anplwaye
C-3I (10/12) Richiesta di indennizzo da parte del dipendente
C-3K (10/12) 직원 청구서뉴욕주
C-3P (10/12) Wniosek pracownika
C-3R (10/12) Заявление работника
C-3.1 (3/04)
C-3.1S (Spanish version) on reverse
Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider Employee Completed by injured employee when employer who is not part of a PPO or ADR program wishes to recommend a network or provider to such employee for treatment purposes. The form is maintained by employer and is not submitted to the Board. The consent shall not be executed prior to the occurrence of employee's work-related injury or illness, but must be executed prior to an employer, who is not part of a PPO or ADR program, recommending a network or provider to an injured employee for treatment purposes.
C-3.1C (10/12) 关于选择劳工赔偿局授权医疗服务提供者的权利的通知
C-3.1H (10/12) Avi pou Dwa pou Chwazi yon Founisè Swen Sante ki Gen Otorizasyon Komisyon Konpansasyon Travayè
C-3.1I (10/12) Informativa sul diritto di scelta di un professionista/struttura sanitaria autorizzato dalla Workers' Compensation Board
C-3.1K (10/12) 근로자재해보상위원회가 승인한 의료 제공자를 선택할 권리에 관한 통지서
C-3.1P (10/12) Informacja o prawie do wyboru dostawcy usług medycznych zatwierdzonego przez Komisję ds. Odszkodowań Pracowniczych
C-3.1R (10/12) Извещение о праве выбора поставщика медицинских услуг, уполномоченного Управлением по компенсациям работникам
C-3.3 (12/09) Limited Release of Health Information (HIPAA) Claimant Workers' Compensation Board If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current Claim, fill out this form.
C-3.3S (10/12) Divulgación limitada de información sobre la salud
C-3.3C (10/12) 健康信息的有限披露 (HIPAA)
C-3.3H (10/12) Divilgasyon Limite Enfòmasyon sou Sante (HIPAA)
C-3.3I (10/12) Richiesta di divulgazione parziale delle informazioni sanitarie (HIPAA)
C-3.3K (10/12) 건강 정보의 제한적 공개 (HIPAA)
C-3.3P (10/12) Ograniczony zakres ujawniania informacji o stanie zdrowia (HIPAA)
C-3.3R (10/12) Ограниченное разрешение на предоставление информации о состоянии здоровья (Закон о преемственности страхования и отчетности в области здравоохранения/HIPAA)
C-21 (1/11) Application for Advance on Periodic Payments of Compensation Claimant Workers' Compensation Board See instructions on form. The application will only be considered if the claim has been finalized with the direction by the Board for continuing payments to the claimant.
C-22 (1/11)

Note: Print form on 14 inch paper.
Application for Approval of Non-Schedule Adjustment Employee and Carrier/Board-approved self-insurer Workers' Compensation Board (One copy only: quadruplicate filing is no longer required.) This is a joint application by employee and carrier/employer to close case on a non-schedule adjustment. It must be signed by all parties in the case.
C-25 (1/11) Application for Reopening of Claim, More Than Seven Years After Accident Employee Workers' Compensation Board When applying to reopen case more than seven years after date of accident. File with Form C-27 doctor's report (see below) if required.
C-32 (11/09) Settlement Agreement,
Section 32
Parties in Interest Form must be signed by all parties in interest and mailed to WCB (or presented at hearing). Agreement may be filed at any time during an open and pending case, and may cover any and all issues.
C-32.1 (1/11) Section 32 Settlement Agreement: Claimant Release Party Submitting Section 32 Settlement Agreement Workers' Compensation Board Completed and notarized Form C-32.1 must be filed along with Form C-32, Settlement Agreement.
C-62 (1/11) Claim for Compensation in Death Case Claimant (The claimant is the surviving spouse, child or dependent of the deceased. See the reverse of the form for details on who may file a claim in a death case.) Workers' Compensation Board in the event of on-the-job death. Within two years of accidental death.
C-62S (10/12) RECLAMO DE COMPENSACIÓN EN CASO DE FALLECIMIENTO DEL TRABAJADOR
C-62C (10/12) 死亡情况下的索赔
C-62H (10/12) REKLAMASYON POU KONPANSASYON NAN YON KA LANMÒ
C-62I (10/12) RICHIESTA DI INDENNIZZO IN CASO DI MORTE
C-62K (10/12) 사망 케이스의 보상 청구
C-62P (10/12) WNIOSEK O ODSZKODOWANIE Z TYTUŁU ZGONU
C-62R (10/12) ЗАЯВЛЕНИЕ НА ВЫПЛАТУ КОМПЕНСАЦИИ В СЛУЧАЕ СМЕРТИ РАБОТНИКА
C-121 (1/11) Claim for Compensation and Notice of Commencement of Third Party Action Employee Workers' Compensation Board, the employer and insurance carrier. Within 30 days after third party action has been commenced.
C-257 (9/10) Claimant's Record of Medical and Travel Expenses and Request for Reimbursement Claimant Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. As needed. Include copies of all receipts and bills, if possible.
C-258 (8/10) Claimant's Record of Job Search Efforts/Contacts Unemployed claimant classified as having a permanent partial disability Do not send this form to the Workers' Compensation Board or the insurance carrier. You may be asked to present a list to evaluate your work search efforts at a hearing. This form is to assist you in an independent job search. List all the employers, employment agencies and labor unions you have contacted while receiving workers' compensation benefits.
C-300.34 (10/97) Statement of Unresolved Issues (Special Part for Expedited Hearings) Parties in Interest Workers' Compensation Board, with copies to all other parties in interest. Within 20 days after case is ordered transferred to the Special Part for Expedited Hearings.
C-300.5 (7/97) Stipulation Employee (and Attorney or Representative, if represented) and Carrier/Board-approved self-insurer Workers' Compensation Board To be used for stipulations to uncontested facts or proposed findings, pursuant to 12NYCRR 300.5.
C-312.5 (12/10) Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only) Claimant (if represented) and Carrier/Board-approved self-insurer Workers' Compensation Board In cases where the claimant is represented, this form is to be used by the parties to propose findings and awards pursuant to 12NYCRR 312.5.
C-430S (1/11) Statement of Rights (WCL) Insurance Carrier/Board-approved self-insurer Sent to injured employee. Within 14 days of receipt of Form C-2 from employer, or with initial benefit check, whichever is earlier.
CB-11 (11/06) Claimant's Guide to the Conciliation Process N/A N/A This is an informational form that the Board uses to advise claimants and insurance carriers of their rights and responsibilities in the Conciliation Process.
CB-11S (1/07) Guia Para Reclamantes Sobre El Proceso De Conciliación N/A N/A Esta es una forma informativa que la Junta utiliza para orientar a los reclamantes de sus derechos y responsabilidades en el Proceso de Conciliación.
DC-120 (1/11) Discharge or Discrimination Complaint Employee who is alleging that an employer has discharged or discriminated against him/her because he/she has claimed or attempted to claim compensation. File two copies of Form DC-120 with:
Workers' Comp. Board
Discrimination Unit
111 Livingston St.
Room 2317
Brooklyn, NY 11201
Any complaint alleging an unlawful discriminatory practice must be filed within two years of the commission of such practice.
DD-1 (2/06) Direct Deposit of Benefit Authorization Form A claimant who is receiving regular, continuing workers' compensation lost wage benefits and wishes to have his/her workers' compensation benefit checks directly deposited into a checking or savings account at a financial institution. Insurance Carrier or Board-approved self-insured employer.
DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD.
Please note: current law does not mandate that all carriers offer direct deposit. Check with the carrier before filing.
Please read all information and instructions on the reverse of the form.
DD-2 (9/05) Biannual Recertification to Entitlement to Benefits A claimant who is having benefit checks directly deposited in a financial institution. Insurance Carrier or Board-approved self-insured employer.
DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD.
Every six months, upon receipt of the form from the carrier/Board-approved self-insured employer.
DT-1 (3/12) Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider Insurance Carrier or Diagnostic Testing Network Copy to employee and his/her representative, and health provider. To Claimant when the statement of Claimant's Rights is mailed - within 14 days of C-2 or with first check per WCL 110 OR when the carrier contracts with a DTN

To medical provider when carrier contracts with a DTN, or at time of first medical bill.
HIPAA-1 (12-03) Claimant's Authorization to Disclose Health Information (Pursuant to HIPAA) Claimant Give the completed form to your doctor, who will keep it with your records. THIS FORM SHOULD NOT BE FILED WITH THE WORKERS' COMPENSATION BOARD. Click here for Workers' Compensation Guidelines on HIPAA Restrictions and Medical Records
IG-1 (5-08) Fraud Complaint Anyone Suspecting Workers' Compensation Related Fraud Workers' Compensation Board, Fraud Inspector General,
100 Broadway - Menands, Albany, NY 12241
When Fraud is Suspected
LAC-1 (4-13) Language Access Comment Form Form is for both internal and external use. Workers' Compensation Board New York State’s policy is to provide language access to public services and programs. If you feel that we have not provided you with adequate interpretation services or have denied you an available translated document, please ask for our complaint form to give us your feedback.
LAC-1S (10/12)

La política del Estado de Nueva York incluye proveer servicios lingüísticos en la prestación de servicios y programas públicos. Si usted cree que no se le ha brindado un servicio adecuado de interpretación o que se le ha negado un documento disponible en versión traducida, por favor solicite un formulario de queja y háganos saber su experiencia.

Formulario para Comentarios sobre el Acceso a Servicios de Idiomas
LAC-1C (10/12)

紐約州政策要求提供公共服務和計畫的語言協助。如認為我們未為您提供充分的口譯服務,或拒絕為您提供現有可用翻譯文件,請索取投訴表,向我們表達反饋意見。

语言服务意见表
LAC-1H (10/12)

Règleman Eta New York se pou bay aksè nan lang nan sèvis ak pwogram piblik yo. Si ou panse nou pa t ba ou sèvis entèpretasyon konvnab oswa si nou te ba ou refi pou yon dokiman tradui ki disponib, tanpri mande fòm plent nou an pou ban nou remak ou.

Fòm Kòmantè sou Aksè nan Lang
LAC-1I (10/12)

La politica di Stato di New York offre assistenza linguistica nei servizi e programmi pubblici. Se si ritiene di non avere ricevuto un servizio di interpretariato adeguato o se è stata rifiutata la traduzione di un documento, è possibile richiedere il nostro modulo di reclamo per comunicare il proprio feedback.

Modulo di reclamo sui servizi linguistici forniti
LAC-1K (10/12)

뉴욕주의 정책은 공공서비스와 프로그램들을 접근하는 언어를 제공하는 것 입니다. 만일 여러분께서 우리가 적절한 통역서비스 제공하지 않았거나 유효한 번역서류를 거부했다고 생각되시면, 귀하의 피드백을 주실 불만신고 양식을 요청하시기 바랍니다.

언어 접근 코멘트 양식
LAC-1P (10/12) Formularz zażalenia na brak dostępu do usług tłumaczeniowych
LAC-1R (10/12)

Руководящим принципом администрации штата Нью-Йорк является предоставление услуг языкового доступа к общественным службам и программам. Если вам кажется, что вам не предоставили надлежащие переводческие услуги или что вам отказали в доступе к тому или иному переведенному документу, попросите, пожалуйста, бланк жалобы и поделитесь с нами своим мнением об этом.

Бланк для комментариев относительно языковой доступности
OC-110A (1/11) Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) Claimant Workers' Compensation Board Claimant must submit form with original signature in order to allow release of his/her records to parties not otherwise authorized to receive them.
OC-110AS (1/11) AUTORIZACIÓN DE RECLAMANTE PARA PERMITIR ACCESO A EXPEDIENTES ANTE LA JUNTA Reclamante Radicado en Oficina Distrito WCB Reclamante deberá someter forma firmada en su original para autorizar acceso a su expediente a personas o entidades usualmente no autorizadas para recibirlos.
OC-110AC(10/12) 索赔人对劳工赔偿记录之披露授权
OC-110AH(10/12) OTORIZASYON MOUN KI MANDE KONPANSASYON POU DIVILGE DOSYE KONPANSASYON TRAVAYÈ
OC-110AI(10/12) AUTORIZZAZIONE DEL RICHIEDENTE ALLA DIVULGAZIONE DEGLI ATTI DELL'INDENNIZZO PER INFORTUNIO SUL LAVORO
OC-110AK(10/12) 뉴욕주 직원상해보험위원회 직원 상해보험 기록 공개에 대한 청구인의 승인
OC-110AP(10/12) UPOWAŻNIENIE DO UJAWNIENIA AKT SPRAWY O ODSZKODOWANIE PRACOWNICZE
OC-110AR(10/12) РАЗРЕШЕНИЕ ЗАЯВИТЕЛЯ НА РАСКРЫТИЕ СВОЕГО ДОСЬЕ ПО КОМПЕНСАЦИИ
RB-89 (1/11) Cover Sheet - Application for Board Review Party applying for Board Review of WC Law Judge decision Workers' Compensation Board, copy to all other parties of interest. Within 30 days after notice of filing of the decision of the WC Law Judge.
RB-89.1 (1/11) Cover Sheet - Rebuttal of Application for Board Review Party rebutting application for Board Review of WC Law Judge decision Workers' Compensation Board, copy to all other parties of interest. Within 30 days after service of the application for review upon the party making the rebuttal.
RB-89.2 (1/11) Cover Sheet – Application for Reconsideration / Full Board Review Party applying for Full Board Review of Board Panel decision. Workers' Compensation Board, copy to all other parties of interest. Within 30 days after notice of filing the decision of the Board Panel.
RB-89.3 (1/11) Cover Sheet – Rebuttal of Application for Reconsideration / Full Board Review Party rebutting application for Full Board review of Board Panel decision Workers' Compensation Board, copy to all other parties of interest Within 30 days after service of the application for Full Board Review upon the party making the rebuttal.
RFA-1W (1/11) Paper Version


[RFA-1W On-line Submission]
Request for Assistance by Injured Worker Claimant Workers' Compensation Board The form may be filed at any time after the Board assigns a WCB case number, or any time after the Board has indicated that no further action (NFA) will be taken. REPLACES FORM RFA-1
VDF-1 (1/12)

[VDF-1 On-line Submission]
Loss of Wage Earning Capacity Vocational Data Form Claimant Workers' Compensation Board, copy to insurance carrier Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.
VDF-1S (10/12) Pérdida de la capacidad de generar ingresos Formulario de datos profesionales
VDF-1C (10/12) 丧失赚取收入能力职业数据表
VDF-1H (10/12) Pèt Mwayen pou Touche Salè Fòm Enfòmasyon Pwofesyonèl
VDF-1I (10/12) Perdita della capacità di guadagno del salario Modulo per i dati professionali
VDF-1K (10/12) 임금획득능력의 상실 직업 데이터 양식
VDF-1P (10/12) Utrata możliwości zarobkowania Formularz danych na temat pracy zawodowej
VDF-1R (10/12) Потеря трудоспособности Бланк для информации о профессиональном образовании и трудовой деятельности
WTC-12 (11/13) Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL §162 Employees or volunteers who participated in World Trade Center rescue, recovery and clean-up operations between 9-11-01 and 9-12-02. Workers' Compensation Board Not later than September 11, 2014
WTC-12S (11/13) Registro de participación en las operaciones de rescate, recuperación y/o limpieza del World Trade Center; Declaración jurada en virtud de la sección 162 de la Ley de compensación de trabajadores (WCL) Empleados o voluntarios que participaron en las operaciones de rescate, recuperación y limpieza del World Trade Center entre el 9-11-01 y 9-12-02. Junta de Compensación para los Trabajadores A más tardar el 11 de septiembre de 2014
WTC-12C (11/13) 参与世界贸易中心救援、恢复和/清理行动登记: (依照 WCL §162 宣誓声明) 于 2001 年 9 月 11 日至 2002 年 9 月 12 日之间参加世界贸易中心救援、恢复和清理行动的雇员或志愿者。 劳工赔偿局 不迟于2014年9月11日
WTC-12H (11/13) Enskripsyon pou Patisipasyon nan Operasyon Sekou, Redrèsman ak/oswa Netwayaj na World Trade Center: Deklarasyon sou Sèman Dapre WCL §162 Anplwaye oswa volontè ki te patisipe nan Operasyon Sekou, Redrèsman ak/oswa Netwayaj na World Trade Center ant 11 septanm 2001 ak 12 septanm 2002. Komisyon Konpansasyon Travayè Anvan 11 septanm 2014
WTC-12I (11/13) Registrazione di partecipazione alle operazioni di soccorso, recupero e/o rimozione di detriti relative al World Trade Center: dichiarazione giurata ai sensi del Comma 162 della WCL Dipendenti o volontari che abbiano partecipato alle operazioni di soccorso, recupero e rimozione di detriti relative al World Trade Center nel periodo compreso tra l'11-09-01 e il 12-09-02. Workers' Compensation Board (Comitato infortuni sul lavoro) Entro e non oltre l'11 settembre 2014
WTC-12K (11/13) 월드트레이드센터 구조, 복구 및/또는 청소 업무 참가 등록: 근로자 보상법(WCL) 162에 따른 선서진술서 2001년 9월 11일과 2002년 9월 12일에 월드트레이드센터 구조, 복구 및/또는 청소 업무에 참가한 피고용자 또는 자원봉사자. 근로자 보상 위원회 2014년 9월 11일까지 제출
WTC-12P (11/13) Zgłoszenie uczestnictwa w akcji ratowniczej, usuwaniu skutków katastrofy i/lub czynnościach porządkowych wykonywanych na terenie World Trade Center: Oświadczenie pod przysięgą zgodne z §162 WCL Pracownicy lub wolontariusze, którzy uczestniczyli w akcji ratowniczej, usuwaniu skutków katastrofy i/lub czynnościach porządkowych wykonywanych na terenie World Trade Center w okresie od 11 września 2001 do 12 września 2002 Worker’s Compensation Board (Urząd Odszkodowań Pracowniczych) Do 11 września 2014 r.
WTC-12R (11/13) Регистрация факта участия в спасательных, восстановительных работах и (или) разборе завалов Всемирного торгового центра: заявление под присягой в соответствии со ст. 162 Закона о компенсации работникам Работники или волонтеры, принимавшие участие в спасательных, восстановительных работах и разборе завалов Всемирного торгового центра в период с 11 сентября 2001 г. до 12 сентября 2002 г. Совет по компенсациям работникам Не позднее 11 сентября 2014 г.
WTCVol-3 (2/04) World Trade Center Volunteer's Claim for Compensation Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Staten Island Landfill on or after 9-11-01 NYS Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 Within two years of injury/illness or within two years after volunteer knew or should have known that injury or illness was related to volunteer service.
W-32R (3/11) WAMO Settlement Agreement-Section 32 Parties of Interest To obtain WAMO signature, mail to:
Waiver Agreement Management Office (WAMO)
NYS Workers' Compensation Board
328 State Street Schenectady, NY 12305-2318.
When all POIs have signed, mail to the WCB District Office.
Special Disability Funds must have all or partial liability. May be filed at any time during an open and pending case, and may cover any and all issues.

If the form you are looking for is not listed above, or in the list of Common Board Forms, please e-mail the Board's Forms Department.