| Product |
SKU |
More Info
|
| 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 |
|
Live Chat
