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Workers' Compensation Board

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Workers' Compensation Forms for
Volunteer Firefighters and Volunteer Ambulance 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 Volunteer Firefighters and Volunteer Ambulance Workers Forms

Form Number /
Version Date
Form Title Who Files Where to File When to File
IG-1 (1-16) Workers’ Compensation Fraud Inspector General Complaint Form Anyone suspecting workers’ compensation-related fraud OR anyone suspecting an EMPLOYER is violating workers’ compensation coverage requirements, such as no coverage, underreporting or concealing information, employer misclassifying employees. Workers’ Compensation Fraud
Inspector General,
Empire State Plaza,
Building 2, 16th Floor,
Albany, NY 12223
When fraud is suspected.
LAC-1 (11-16) 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 (11/16)

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 (11/16)

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 (11/16)

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 (11/16)

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 (11/16)

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 (11/16) Formularz zażalenia na brak dostępu do usług tłumaczeniowych
LAC-1R (11/16)

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
VAW-1 (8/97) Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death Volunteer Ambulance Worker Send to political subdivision liable for benefits. [This is not a claim for benefits. See VAW-3] Within 90 days after date of injury or death (unless claim form VAW-3 or VAW-62 is filed within that period).
C-2F (1/14) Paper Version

[C-2F Instructions]

VAW-2
(obsolete)
Political Subdivision's Report of Injury to Volunteer Ambulance Worker Political Subdivision (contact your claim administrator who can provide advice for the best method to report the information.) Workers' Compensation Board Within 10 days after injury is incurred.
VAW-3 (1/11) Volunteer Ambulance Worker's Claim for Benefits Volunteer Ambulance Worker Workers' Compensation Board, and political subdivision liable for benefits. [If filed within 90 days of injury, it is not necessary to file VAW-1.] Within 2 years after injury is incurred.
VAW-62 (1/11) Claim for Volunteer Ambulance Workers' Benefits in a Death Case Claimant Workers' Compensation Board and designated officer (see detailed instructions on form) Within two years after death (but see also Form VAW-1)
VAW-105 (9/16) Notice of Compliance - Volunteer Ambulance Workers' Law Political Subdivision or Unaffiliated Volunteer Ambulance Service insured for Volunteer Ambulance Workers' Benefits through an insurance carrier or Board-approved self-insurance. This form is not filed. It must be completed by the insurance carrier or self-insured political subdivision or unaffiliated ambulance service with identifying insurance information and then displayed in the ambulance company headquarters. Upon securing of volunteer ambulance workers' insurance or self-insurance. Political subdivisions or unaffiliated ambulance services must obtain this form from their insurance carrier or group self-insurance administrator.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
VF-1 (8/97) Notice to Political Subdivision of Volunteer Firefighter's Injury or Death Volunteer Firefighter Send to political subdivision liable for benefits. [This is not a claim for benefits. See VF-3] Within 90 days after date of injury or death (unless claim form VF-3 or VF-62 is filed within that period)
C-2F (1/14) Paper Version

[C-2F Instructions]

VF-2
(obsolete)
Political Subdivision's Report of Injury to Volunteer Firefighter Political Subdivision (contact your claim administrator who can provide advice for the best method to report the information.) Workers' Compensation Board Within 10 days after injury is incurred.
VF-3 (1/11) Volunteer Firefighter's Claim for Benefits Volunteer Firefighter Workers' Compensation Board, and political subdivision liable for benefits. [If filed within 90 days of injury, it is not necessary to file VF-1.] Within 2 years after injury is incurred.
VF-62 (1/11) Claim for Volunteer Firefighter Benefits in a Death Case Claimant Workers' Compensation Board and designated officer (see detailed instructions on form) Within two years after death (but see also Form VF-1)
VF-105 (9/16) Notice of Compliance - Volunteer Firefighters Benefit Law Political Subdivision insured for Volunteer Firefighters' Benefits through an insurance carrier or Board-approved self-insurance. This form is not filed. It must be completed by the insurance carrier or self-insured political subdivision with identifying insurance information and then displayed in the firehouse and fire company headquarters. Upon securing of volunteer firefighters' insurance or self-insurance. Political subdivisions must obtain this form from their insurance carrier or group self-insurance administrator.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
VF/VAW-10 (10-06) Carrier's Request for Benefit Increase Reimbursement Under Sec. 51 VFBL/VAWBL Insurance Carrier/Self-Insurer Forward original and one copy, along with any required documentation to:
Workers' Compensation Board, Fund for Reopened Cases Unit
328 State Street Schenectady, NY 12305-2318
Claims for reimbursement should be submitted for 52 week periods, beginning one year from the date of the first payment, and annually thereafter while payments continue.
VF/VAW-11C
(1/11)
Volunteer's Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV Per VFBL/VAWBL Section 11-c(1) Volunteer Firefighter or Volunteer Ambulance Worker Executive Officer of Fire Company or Ambulance Company, copy to the Workers' Compensation Board Following significant risk of transmission of HIV incurred in the line of duty as a volunteer firefighter or ambulance worker.

Executive Officer must authorize appropriate medical examination within 8 hours of receipt of Form VF/VAW-11C. Contact the nearest office of the Workers' Compensation Board if authorization is not granted within that time.

THIS FORM IS NOT A NOTICE OF INJURY/OCCUPATIONAL DISEASE OR A CLAIM FOR BENEFITS UNDER THE VFBL OR VAWBL. (See Forms VF-1, VAW-1, VF-3 and VAW-3)
WTC-12 (9/16) 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, 2018
WTC-12S (9/16) 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 2018
WTC-12C (9/16) 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2018年9月11日
WTC-12H (9/16) 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 2018
WTC-12I (9/16) 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 2018
WTC-12K (9/16) 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 2018년 9월 11일까지 제출
WTC-12P (9/16) 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 2018 r.
WTC-12R (9/16) 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 2018 г.
WTC-16 (7/07) Cover Sheet: List of Itemized Medical Bills for Temporary Payment by the World Trade Center Volunteer Fund in Controverted World Trade Center Case Insurance Carrier or Board-approved Self-Insurer Workers' Compensation Board Initially within 15 days and monthly thereafter
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.

If the form you are looking for is not listed above, or in the list of Common Board Forms, please email the Board.