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To file a
Workers' Compensation claim, several forms may be necessary. Please
report claims by filing all applicable forms with FDM
and the New York State Workers' Compensation Board. Be sure that all
claim forms are sighed by an authorized representative.
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C-2 |
This form is the
fire/ambulance district's report of injury for a paid employee. |
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C-3 |
This form is similar
to the VF-3 and VAW-3 form. It is a claim for benefits fro lost
time form your regular employment, completed by the injured
employee. |
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C-11 |
This form is the
fire/ambulance district's report of a injured employee's change
in employment status resulting form injury. Also, please include
the employee's date of return to employment |
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C-240 |
This form is the
fire/ambulance district's statement of wage earnings preceding
the accident. |
Filing procedures for claims under the Worker's Compensation Laws are
basically the same as for Volunteer Firefighters' Benefit Law Coverage.
The form to be used is the C-2, which must be filed within 10 days of
the injury. The form C-2 is to be used to report all injuries.
Fire Commissioners and other
fire or ambulance district officers who receive no
compensation: Section 2 (9) of the Workers' Compensation Law
states that in the case of an officer, whether elected or
appointed, and whether or not he/she is compensated for
his/her services, the rate of compensation to be paid will
depend on the amount of his/her regular wages. In no event
shall the average weekly wage be fixed at less the $30. This
means that, if a commissioner is injured, he/she will be
entitled to have their medical bills paid and will receive
at least $30 per week for whatever period beyond 7 days
he/she is incapacitated. |
For all paid employees
the weekly rate of compensation is figured on the average
weekly wages earned in the employment in which he/she was
injured during the year PRIOR to the accident. Compensation
begins on the eighth day after the injury, unlike VFBL or VAWBL payments which begin the day of
the injury. The rate is 2/3 of the average weekly salary.
When a paid employee
wished to be compensated for lost time from work due to
his/her injury, then form C-3 must be filed.
When requested, the
district should prepare a form C-240. This is a record of the injured
party's earnings for the year prior to the accident. Two copies of this
form are to be sent to FDM. The gross earnings must be shown. Do
not show any deductions for taxes, social security, etc.
When an injured
employee returns to work, the fire/ambulance district should immediately
file a form C-11, an "Employer's Report of Injured Employee's
Change in Employment Status Resulting from Injury". This form
is to be filed when:
- The employee returns to work
- If there is a discontinuance
of work
- If the regular hours of work
increase or decrease
- If there is a increase or
reduction of wages
This form should be
prepared as four copies, one copy to be sent to the Worker's
Compensations Board, two copies to FDM and one copy should
be kept by the district.
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