Registration Of Participation In WTC Rescue Recovery Clean-Up Operations {WTC-12}

WTC-12 - REGISTRATION OF PARTICIPATION IN WORLD TRADE CENTER RESCUE, RECOVERY AND/OR CLEAN-UP OPERATIONS (Affirmation Pursuant to Workers' Compensation Law §162). If you were a "participant" in World Trade Center rescue, recovery, and/or cleanup operations, as that term is defined above, you are required to provide information requested by the Board in the accompanying Affirmation if you were exposed to hazardous conditions which cause you to suffer, or may cause you to suffer in the future, from a "qualifying condition" for which you will or may file or have filed a claim for workers' compensation benefits. The form collects personal information, such as the participant's name, address, contact details, and evidence of volunteer activities. It also requires the participant to provide details about their participation, including dates, locations, work performed, employer or agency involved, and insurance carrier if applicable. The form includes a declaration stating that the participant has or has not filed a claim with the Workers' Compensation Board and acknowledges the penalties for making false statements. The form must be notarized by a notary public. www.FormsWorkflow.com