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New York Affidavit for Death Benefits FFNY150
New York Affidavit for Death Benefits (Dependent Brothers/Sisters/Grandchildren), AFF-2 (2/04) FFNY205
New York Affidavit for Death Benefits (Dependent Parents/Grandparents), AFF-3 (2/04) FFNY210
New York Affidavit for Death Benefits (dependents) FFNY155
New York Affidavit For New York Entities With No Employees And Certain Out Of State Entities WC/DB-100 (9/07) FFNY035
New York Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance, BP-1 (9/07) FFNY215
New York Alternative Dispute Resolution Program Final Disposition or Settlement of Claim ADR-2 (8/03) FFNY615
New York Alternative Dispute Resolution Program Report of Injury ADR-1 (11/06) FFNY605
New York Alternative Dispute Resolution Program. Modification of Previous Report ADR-1.1 (1/08) FFNY610
New York Application for Acceptance of Insurance Form DB-850 (3/02) FFNY865
New York Application for Advance on Periodic Payments of Compensation C-21 (2/04) FFNY250
New York Application for Approval of Non-Schedule Adjustment C-22 (2/04) FFNY255
New York Application for Reopening of Claim, More Than Seven Years After Accident C-25 (8/03) FFNY260
New York Attending Doctor's Report, C-4 (7/07) FFNY235
New York Attending Doctor's Request for Medical Authorization Determination MD-1 (7/07) FFNY360
New York Attending Opthamologist's Report, C-5 (7/07) FFNY245
New York Attending Psychologist's Report, PS-4 (7/07) FFNY400
New York Attorney/Representative's Application for Fee OC-400.1 (11/06) FFNY385
New York Authorization for claimants to allow access to records before the Board (Spanish) OC-110AS FFNY375
New York Biannual Recertification to Entitlement to Benefits DD-2 (9/05) FFNY320
New York Carrier/Board-approved self-insured employer's Objection to Attending Doctor's Request MD-3 (12/03) FFNY830
New York Carrier's Designation of Authorized Representatives DB-840 (2/00) FFNY860
New York Carrier's Report on Rehabilitation, R (8/05) FFNY835
New York Carrier's Request for Benefit Increase Reimbursement Under Sec. 51 VFBL/VAWBL, VF/VAW-10 (10-06) FFNY845
New York Carrier's Request for Reimbursement of Compensation Payments Under Section 14(6) C-251.2 (11/01) FFNY770
New York Carrier's Request for Reimbursement of Compensation Payments Under Section 15-8 C-251 (11/01) FFNY760
New York Carrier's Request for Reimbursement of Medical Expenses Under Section 15-8 C-251.1 (11/01) FFNY765
New York Carrier's/Employer,s Request for Further Action, RFA-2 (3/08) FFNY840
New York Claim for Compensation and Notice of Commencement of Third Party Action C-121 (8/03) FFNY275
New York Claim for Compensation in Death Case C-62 (8/03) FFNY875
New York Claim for Volunteer Ambulance Workers' Benefits in a Death Case, VAW-62 (8/03) FFNY900
New York Claim for Volunteer Firefighter Benefits in a Death Case, VF-62 (8/03) FFNY920
New York Claimant's Authorization to Disclose Health Information (Pursuant to HIPAA) HIPAA-1 (12-03) FFNY330
New York Claimant's Authorization to Disclose Workers' Compensation Records (Section 110-a) OC-110A (8/07) FFNY370
New York Claimant's Guide to the Conciliation Process CB-11 (11/06) FFNY290
New York Claimant's Notice of Independent Medical Examination IME-5 (2/07) FFNY825
New York Claimant's Record of Medical and Travel Expenses C-257 (10/07) FFNY280
New York Claimant's Request for Further Action, RFA-1 (3/08) FFNY405
New York Continuation to Carrier/Employer Billing Portion, C-4.1 (6/04) FFNY240
New York Cover Sheet - Application for Board Review RB-89 (9/05) FFNY025
New York Cover Sheet - Rebuttal of Application for Board Review RB-89.1 (9/05) FFNY030
New York Direct Deposit of Benefit Authorization Form DD-1 (2/06) FFNY315
New York Discharge or Discrimination Complaint DC-120 (11/06) FFNY310
New York Election of a Corporation Which is Required to Have Disability Benefits Coverage DB-212.3 (1/04) FFNY715
New York Employee's Claim for Compensation FFNY160
New York Employee's Claim for Compensation, C-3 (11/06) FFNY220
New York Employee's Statement of Exempt Status DB-130 (5/02) FFNY300
New York Employer Fraud Referral Form IG-2 (5-08) FFNY015
New York Employer Identification Card FFNY165
New York Employer Identification Card DB-125 (2/05) FFNY695
New York Employer's Application for Voluntary Coverage for Class of Employees DB-135 (8/03) FFNY700
New York Employer's Application for Voluntary Coverage for Class of Employees DB-136 (8/03) FFNY705
New York Employer's Application to Have Association, Union or Trustee Plan DB-802 (4/04) FFNY725
New York Employer's Report of Accident C-2 (11/06) FFNY620
New York Employer's Report of Injured Employee's Change in Status or Return to Work C-11 (8/03) FFNY625
New York Employer's Statement for the Purpose of Terminating Status as a Covered Employer DB-118 (10/07) FFNY690
New York Employer's Statement of Wage Earnings Preceding Date of Accident C-240 (8/03) FFNY680
New York Fraud Complaint IG-1 (5-08) FFNY010
New York Guide To Claimants on the process of conciliation (Spanish) CB-11S (1/07) FFNY295
New York Health Insurer's Request for Reimbursement HIMP-1(10/04) FFNY815
New York Health Provider's Application for Authorization Under the Workers' Compensation Law MR/IME-1 (4/05) FFNY365
New York Health Provider's Request for Decision on Unpaid Medical Bill(s) HP-1 (4/05) FFNY335
New York Important Information for Employers Operating in New York State OC-923 (3/08) FFNY020
New York Information for Employer Regarding Disability Benefits Law DB-102 (10/07) FFNY685
New York Instructions for Completing Affidavit for Death Benefits, AFF-1 (7/04) FFNY200
New York List of Itemized Medical Bills for Temporary Payment by the World Trade Center, WTC-16 (7/07) FFNY850
New York Medical Proof of Change in Condition in Support of Application for Reopening C-27 (8/03) FFNY265
New York Notice and Proof of Claim for Disability Benefits FFNY170
New York Notice and Proof of Claim for Disability Benefits DB-450 (2/04) FFNY410
New York Notice of Claim for Reimbursement Out of Special Disability Fund Under Section 15-8 C-250 (3/07) FFNY755
New York Notice of Disability Benefits Payment DB-455 (3/99) FFNY800
New York Notice of Election of a Municipal Corporation or other Political Subdivision C-105.31 (1/04) FFNY645
New York Notice of Election of a Not-for-Profit Corporation or Unincorporated Association C-105.52 (1/04) FFNY660
New York Notice of Election of a Partnership C-105.32 (4/04) FFNY870
New York Notice of Election to Bring Sheltered Workshop Participants Under Coverage of WCL C-105.54 (3/99) FFNY670
New York Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers C-105.51 (1/04) FFNY655
New York Notice of Election to Voluntarily Exclude Spouse from Coverage DB-212.5 (11/06) FFNY735
New York Notice of Proof of Claim for Disability Benefits of Unemployed Claimant DB-300 (2/04) FFNY305
New York Notice of Retainer and Appearance on Behalf of Employer OC-406 (5/08) FFNY730
New York Notice of Retainer and Substitution OC-400 (4/08) FFNY380
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