Notice of Volunteer Ambulance Worker's Injury or Death for Workers' Compensation - New York 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the title and name of the officer to whom the notice is addressed. This ensures that your notice reaches the correct individual responsible for processing.
3. Fill in the details of the volunteer ambulance worker, including their first name, middle initial, last name, and home address. Accurate information here is crucial for identification.
4. Specify the political subdivision or ambulance district involved, if applicable. This section helps clarify which entity is liable for benefits.
5. Provide information about the regular employer of the volunteer ambulance worker, if any. This may be relevant for claims processing.
6. Detail where and when the injury occurred by filling in the address and community. Include both date and time of injury or death to ensure precise documentation.
7. In this section, describe fully the nature and cause of injury or death. Be as detailed as possible to support any future claims.
8. Finally, sign and date the form appropriately. If applicable, include a signature from a person on behalf of the injured worker or dependents.

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