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Request for Assistance by Injured Worker
ERFA-1W

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

ATTENTION: Please read these Instructions before completing and submitting the ERFA-1W.


If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

This form is not to be used to report an injury. To file a claim, use Form C-3.

Required items are indicated by an *.

Case Information
Injured Worker Information
   
* Gender:
Employer Information
The Tax ID # is the (select one):
REASON FOR THIS REQUEST
INSTRUCTIONS: Check all boxes that apply. Be sure to attach additional forms, medical reports, letters, etc. as required for each checkbox. If the additional information was already submitted do not attach it, but try to identify it in the space at the bottom of this form** by giving the form number or title and the date it was submitted to the Board.

Compensation Payments:

and not receiving payments.
(Medical documentation indicating disability required.)
Check all that apply:
 
 
at full pay.
(Attach current pay stub and medical reports from your doctor.)
(Attach weekly gross pay before your injury and statement from second employer regarding lost time.)
and am not receiving payments.
(Attach medical report that shows a medical disability and release from custody papers.)

Medical Issues:

(attach PAR denial)  Review by WCB Adjudication can only be requested if:
 
(Attach any documents that show why the denial was incorrect.)
 
(Attach "Notice of Resolution" regarding treatment.)
(Attach Form C-4.3, Doctor's Report Of MMI/Permanent Impairment.)
(Attach medical forms.)
(Attach receipts and Form C-257.)

Other Issues:

(Attach documents.)
Sign

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

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