Form C-107 - Nysif - Employer'S Request For Reimbursement Page 2
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1
2INSTRUCTIONS
1.
This form is used principally as evidence of a claim for reimbursement by an employer for
monies advanced to a claimant on account of compensation due under the provisions of the
Workers’ Compensation Law.
Attention is drawn specifically to Section 25 of the Workers’ Compensation Law, from which
2.
the following is extracted:
“…If the employer has made advance payments of compensation, or has made payments
to an employee in like manner as wages during any period of disability, he shall be entitled
to be reimbursed out of an unpaid installment or installments of compensation due, provided
his claim for reimbursement is filed before award of compensation is made, or, if insured, by
the insurance carrier at the direction of the board, unless he shall file a waiver of
reimbursement with the chairman, in which event compensation will be paid to the claimant
notwithstanding the advance payments…”
3.
It is recommended that, while payments are being advanced, this form be completed monthly and
mailed to The Workers’ Compensation Board (See below). A copy of this form should
be sent to the State Insurance Fund.
This form should be filed by sending directly to the address listed below:
New York State Workers' Compensation Board
Centralized Mailing
PO Box 5205
Binghamton, NY 13902-5205
Customer Service Toll-Free Number: 877-632-4996
C-107 (12/15)
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