Ny carrier reimbursement 2026

1. Click ‘Get Form’ to open the ny carrier reimbursement document in the editor.
2. Begin by entering the WCB Case Number, Carrier Case Number, and Carrier ID Number at the top of the form. This information is essential for tracking your request.
3. Fill in your Carrier's Name and Address, followed by the Claimant's Name. Ensure all details are accurate to avoid processing delays.
4. In Section A, specify the number of weeks for which you are requesting reimbursement, along with the corresponding dates and amounts paid. Repeat this for each period as necessary.
5. Complete Section B if you are claiming a lump sum payment. Specify the number of weeks and weekly rate.
6. If applicable, fill out Section C for funeral expenses and Section D for any other costs. Be sure to provide clear descriptions.
7. Answer the questions regarding initial requests and third-party actions accurately to ensure proper processing.
8. Finally, certify your request by signing and dating at the bottom of the form before submitting it as instructed.

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