New york c22 2025

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The document is an application form for the approval of a non-schedule adjustment related to workers' compensation claims in New York. It requires detailed information about the claimant, including personal details, employment status, income sources, and medical treatment history. The form also outlines the implications of accepting a lump sum settlement, including the closure of the case and responsibilities for future medical expenses.

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Click ‘Get Form’ to open the New York C22 in the editor.
Begin by filling in the claimant's Social Security Number and W.C.B. Case Number at the top of the form.
Indicate the relevant sections for approval, such as Section 15, Subdivision 5-b, Workers' Compensation Law, by checking the appropriate box.
Provide details about the accident, including dates and locations of injury. Ensure all fields are completed accurately.
List all sources of income other than Workers' Compensation benefits and provide details about dependents relying on the claimant for support.
Complete questions regarding marital status and employment status of the spouse if applicable.
Review all sections carefully before submitting to ensure no information is missing, as incomplete applications may be rejected.

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