Modification Of Previous Report (ADR Program) {ADR-1.1}

NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 Customer Service Toll-Free Line: 877-632-4996 Statewide Fax Line: 877-533-0337 State of New York - Workers' Compensation Board www.wcb.ny.gov Alternative Dispute Resolution Program Modification of Previous Report Complete the identifying information and use the narrative portion to modify, clarify or update information reported on any previously-filed ADR form. INJURED EMPLOYEE (First Name, Middle Initial, Last Name) EMPLOYEE'S ADDRESS (Street No. & Name, Apt. No, City, State and Zip Code) DATE OF INJURY WCB CASE NUMBER UNION NAME & LOCAL NUMBER INSURANCE CARRIER'S NAME AND MAILING ADDRESS EMPLOYER'S NAME AND MAILING ADDRESS FILING ENTITY: Employer Carrier Other (If "Other", give name and address.) CARRIER CASE NUMBER CARRIER ID NUMBER WNARRATIVE Prepared by Date of this Report Official Title Telephone Number & Extension ADR-1.1 (1-11) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. American LegalNet, Inc. www.FormsWorkFlow.com