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 624 State Forms found

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Insurer's Request For Reimbursement Of Indemnity Payments Under WCL Section 14(6) Or Section 15(8)

C-251 (1/18)

Insurer's Request for Reimbursement of Medical Payments Under WCL Section 15(8)

 C-251.1 (5-22)

CERTIFICATE OF EXCESS INSURANCE CONTRACT FOR SELF-INSURER

 SI-21 (09/19)

SUPPLEMENT TO CERTIFICATE OF INSURANCE

 DB-820.1 (3-18)

CLAIM FOR COMPENSATION AND NOTICE OF COMMENCEMENT OF THIRD PARTY ACTION

C-121 (1-11)

CLAIM FOR COMPENSATION IN A DEATH CASE

 C-62 (1-11)

CLAIM FOR VOLUNTEER AMBULANCE WORKERS' BENEFITS IN A DEATH CASE

 VAW-62 (1-11)

CLAIM FOR VOLUNTEER FIREFIGHTERS' BENEFITS IN A DEATH CASE

 VF-62 (1-11)

CLAIMANT'S AUTHORIZATION TO DISCLOSE HEALTH INFORMATION (Pursuant to HIPAA)

 HIPAA-1 12-03

CLAIMANT'S AUTHORIZATION TO DISCLOSE WORKERS' COMPENSATION RECORDS

 OC-110A (12-17)

CLAIMANT'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION

 IME-5 (5-18)

CLAIMANT'S RECORD OF JOB SEARCH EFFORTS/CONTACTS

 C-258 (5-19)

CLAIMANT'S RECORD OF MEDICAL AND TRAVEL EXPENSES AND REQUEST FOR REIMBURSEMENT

 C-257 (11-21)

CONSENT TO NYS WORKERS' COMPENSATION BOARD JURISDICTION FOR NON-NEW YORK LICENSED CARRIERS (3C COVERAGE)

C-105.11 (1-24)

APPLICATION FOR BOARD REVIEW

 RB-89 (4-24)
Disclaimer: These forms may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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