Form C-251 - Carrier'S Request For Reimbursement Of Compensation Payments - Workers' Compensation Board - State Of New York
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1STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CARRIER'S REQUEST FOR REIMBURSEMENT OF COMPENSATION PAYMENTS UNDER SEC. 15-8
WCB CASE NO.
CARRIER CASE NO.
CARRIER ID NO.
SOC. SEC. NO.
W
CARRIER'S NAME
CARRIER'S ADDRESS
CLAIMANT'S NAME
The Carrier requests reimbursement for benefits paid, as follows:
A. _________ weeks from ________________ to ________________ at $ _________________ $ ________________
__________ weeks from ________________ to ________________ at $ _________________ $ ________________
__________ weeks from ________________ to ________________ at $ __________________$ _______________
B. Lump sum payment representing _____________ weeks at $ __________________per week. $ ________________
C. Funeral Expenses________________________________________________________________ $ _____________
D. Other (Specify) __________________________________________________________________ $ _____________
TOTAL CLAIM FOR REIMBURSEMENT $
1. Does this claim represent an initial request for reimbursement of compensation payments ?
Yes
No
2. Date Claimant's status was last checked_______________________
The summary below is to be used for all initial claims. If desired, Form C-8/8.6 may be substituted and attached to the original copy.
The summary (or Form C-8/8.6) must include all payments from date of accident through the period for which reimbursement is requested.
SUMMARY OF COMPENSATION PAYMENTS
Period(s) of Payments
Less Days
Number of
Weekly Rate
Worked
Weeks
From
To
3. Is there a third party action on this claim?
Yes
No
If yes, is this action
pending
dismissed
settled
S T A T E M E N T
I hereby certify that this request for reimbursement made to the Chair of the Workers' Compensation Board is true and
correct; that no part thereof has been previously paid and the amount stated therein is due and owing.
Signature:_________________________________________________________ Date: ____________________________
Title:__________________________________________________ Telephone No.:____________________________
DO NOT USE SPACE BELOW
INSTRUCTIONS:
TO: CHAIR, WORKERS' COMPENSATION BOARD
1. Where possible, claim should be submitted
The Special Funds Conservation Committee approves reimbursement for the above
for 26 week periods.
claim totaling $_____________________.
2. Forward original and two copies to the local office
of the Special Funds Conservation Committee.
Agreed Date for Compensation Reimbursement___________________________
3. Retain one copy.
By_______________________________
Date__________________________
C-251 (11-01)
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