Claim carrier weekly 2026

The document is a request form for reimbursement of benefit increases under the Volunteer Firefighters' and Volunteer Ambulance Workers' Benefit Laws in New York. It outlines the necessary information regarding original and increased weekly benefit rates, details on compensation or death benefits, lump sum payments, and re-marriage awards. The carrier must certify the accuracy of the request and submit it to the Workers' Compensation Board along with required documentation.

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Click ‘Get Form’ to open the claim carrier weekly document in the editor.
Begin by entering the WCB Case No. and Carrier Case No. at the top of the form. This information is crucial for tracking your claim.
Fill in the Claimant's name and Social Security Number accurately to ensure proper identification.
Specify the Carrier and indicate whether it’s a Volunteer Fire Claim or Volunteer Ambulance Claim by checking the appropriate box.
Input the Carrier Address, followed by detailing the original weekly benefit rates and increased benefit rates as applicable for each date listed.
In section A, provide details on Compensation/Death Benefits, including weeks and amounts paid. Repeat this for any additional claims.
If applicable, complete sections B and C for Lump Sum and Re-marriage Award requests respectively.
Indicate if this is an initial request for reimbursement by selecting 'Yes' or 'No'. If yes, attach required documentation as specified.
Finally, complete the Carrier Statement section by printing or typing your name, signing, providing your telephone number, title, and date.

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