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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 (Chinese)

 A-9 (11-21)

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 (Haitian Creole)

 A-9 (11-21)

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 (Italian)

 A-9 (11-21)

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 (Korean)

 A-9 (11-21)

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 (Polish)

 A-9 (11-21)

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 (Russian)

 A-9 (11-21)

Employee Claim (Chinese)

 C-3.0 (06-22)

Employee Claim (Haitian Creole)

 C-3.0 (6-22)

Employee Claim (Italian)

 C-3.0 (6-22)

Employee Claim (Korean)

 C-3.0 (6-22)

Employee Claim (Polish)

 C-3.0 (6-22)

Employee Claim (Russian)

 C-3.0 (6-22)

Notice of Right to Select a Workers’ Compensation Board Authorized Health Care Provider - English - Chinese Version

 C-3.1C (10-12)

Notice of Right to Select a Workers’ Compensation Board Authorized Health Care Provider - English - Haitian-Creole

 C-3.1H (10-12)

Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider - English - Italian

 C-3.1I (10-12)
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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