nys workers' comp settlement chart Preview on Page 1

New york workers compensation 2026

The document is a Notice of Claim for Reimbursement from the Special Disability Fund under Section 15, Subdivision 8 of the Workers' Compensation Law. It outlines the necessary information required to support a claim for apportionment of liability and reimbursement for compensation or medical expenses related to an injury sustained by an employee. The form requests details about the injured person, employer, carrier, previous impairments, and specifics of the current claim.

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Click ‘Get Form’ to open the New York Workers Compensation form in the editor.
Begin by filling in your W.C.B. Case Number, Carrier Case Number, and Carrier Code at the top of the form. These identifiers are crucial for tracking your claim.
Enter the Date of Injury and your Social Security Number. Ensure that all information is accurate to avoid delays.
Provide your name and address, including any apartment number if applicable. This information helps in identifying you as the injured person.
Fill in details about your employer and the insurance carrier handling your claim. This section is essential for processing reimbursement requests.
Detail any previous physical impairments and their nature, as well as specifics regarding your current claim, including descriptions of injuries and compensation history.
Finally, review all entries for accuracy before submitting. Once completed, mail this form to the appropriate Workers' Compensation Board address based on your location.

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