Form C-107 - Nysif - Employer'S Request For Reimbursement

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N e w Y o r k S t a t e I n s u r a n c e F u n d
NYSIF
199 CHURCH STREET, NEW YORK, NY
199 CHURCH STREET, NEW YORK, NY 10007-1173
10007-1173
EMPLOYER’S REQUEST FOR REIMBURSEMENT
TO:
ADDRESS:
CLAIMANT:
_________________________________________
S.I.F. No:
_______________________________
EMPLOYER:
_________________________________________
W.C.B. No:
_______________________________
_________________________________________
DATE OF ACCIDENT:
_______________________________
____________________________
SEE INSTRUCTIONS ON BACK
_____________________________
To the Workers’ Compensation Board:
The undersigned employer hereby requests FULL REIMBURSEMENT, in accordance with the Workers’ Compensation Law,
for wages advanced during a period of absence due to disability.
The total amount advanced was _____________________________________________________ dollars and
__________________________________ cents ($_____________) for the period from ______________________________
through ____________________________.
EMPLOYER’S REPRESENTATIVE:
DATE: __________________________
Print Name_________________________________
and Title _________________________________
EMPLOYER’S SIGNATURE: _________________________________
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning
any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each violation.
NOTE TO EMPLOYER:
Under current interpretations of Section 25 of the Workers’ Compensation Law, in cases involving temporary disability, an
employer may not recover more than the compensation benefit rate for the period during which compensation or wages were
advanced, nor may there be any reimbursement for the first week if the disability does not exceed two (2) weeks.

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