Carriers Request For Reimbursement Of Compensation Payments Under Section 14(6) (Blue Paper) {C-251.2}

STATE OF NEW YORK www.wcb.ny.gov WORKERS' COMPENSATION BOARD CARRIER'S REQUEST FOR REIMBURSEMENT OF COMPENSATION PAYMENTS UNDER SEC. 14-6 CONCURRENT EMPLOYMENT WCB CASE NO. CARRIER'S NAME CLAIMANT'S NAME CARRIER CASE NO. CARRIER ID NO. SOC. SEC. NO. W CARRIER'S ADDRESS The Carrier requests reimbursement for benefits paid, as follows: A. _________ weeks from ________________ to ________________ at $ _________________ $ ________________ __________ weeks from ________________ to ________________ at $ _________________ $ ________________ __________ weeks from ________________ to ________________ at $ __________________$ _______________ B. Lump sum payment representing _____________ weeks at $ __________________per week. $ ________________ C. Other (Specify) _________________________________________________________________ $ ______________ TOTAL CLAIM FOR REIMBURSEMENT $ 1. Does this claim represent an initial request for reimbursement of compensation payments? Yes If yes, attach Notice of Decision establishing average weekly wage and concurrent employment. 2. Attach copies of all claimant status checks. 3. Form SROI-SA MUST also be submitted. STATEMENT I hereby certify that this request for reimbursement made to the Chair of the Workers' Compensation Board is true and correct; that no part thereof has been previously paid and the amount stated therein is due and owing. No Signature:___________________________________________________________ Date: ___________________________ Title:________________________________________________ Telephone No.:_______________________________ INSTRUCTIONS: 1. Where possible, claim should be submitted for 26 week periods. 2. Forward one copy to the local office of the Special Funds Conservation Committee. 3. Forward original and one copy to Workers' Compensation Board, 328 State Street, Schenectady, NY 12305, ATT: FINANCE OFFICE. 4. Retain one copy. C-251.2 (7-14) American LegalNet, Inc. www.FormsWorkFlow.com