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Workers’ Compensation Forms Volunteer Firefighters and Volunteer Ambulance Workers

Forms

Completing Forms

If you require assistance with completing these forms, please contact us.

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it. If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. If you still have trouble with the form, please email the Board's Forms Department.

Multi-page Forms
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.

Original Signature Requirement

COVID-19 Response: Original Signature Requirement Relief – March 2020

The Workers' Compensation Board does not normally accept a claimant's electronic signature on Board-prescribed forms. Due to recent increases in COVID-19 infection rates across New York State, however, as of August 16, 2021, the Emergency Relief from Signature Requirements on Listed Documents will remain in effect until further notice for the forms specifically listed in the Board's announcement: Emergency Relief from Original Signature Requirements on Listed Documents.

The Board, as standard practice, does not accept electronic signatures on Board-prescribed forms, as the Board is unable to efficiently evaluate the electronic signature process used by an insurer, health care provider, attorney, or licensed representative to ensure that the procedure complies with the New York Electronic Signatures and Records Act (ESRA) and applicable regulations. Therefore, a claimant's ink signature must be supplied when a claimant's signature is required by law.


Popular Forms


Workers' Compensation Forms for Volunteer Firefighters and Volunteer Ambulance Workers
Form Number /
Version Date
Form Title Who Files Where to File When to File
C-2F (1/14) Paper Version

[C-2F Instructions]

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.

LAC-1 (07-22)

[LAC-1 Online Submission]

Right to File a Language Access Complaint

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.
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).
VAW-3 (6/22) 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)
VF-3 (6/22) 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 (12/21) Insurer's Request for Benefit Increase Reimbursement Under Sec. 51 VFBL/VAWBL Insurance Carrier/Self-Insurer Send your request along with any required documentation to: SpecialFunds@wcb.ny.gov 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
(6/22)
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 (9/22) 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, 2026
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
WTC-HIPAA (4/17) World Trade Center Volunteer Health Insurance Portability and Accountability Act Authorization Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board File with Form WTCVol-3. See form for complete instructions.
WTC-VCF-AUTH (4/17) World Trade Center September 11th Victim Compensation Fund (VCF) Authorization Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board File with Form WTCVol-3. See form for complete instructions.
WTCVol-3 (6/22) 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 Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 After filing a timely WTC-12, file a claim. See form for complete instructions.

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