General Information

IMPORTANT NOTICE TO ALL POLICYHOLDERS AND AGENTS

RE: New Claim Submissions:
The Board has introduced a new Form C-2F, Employer's First Report of Work-Related Injury/Illness. This new form has been aligned with the IAIABC Claims Release 3.0 standard and the Board's Element Requirement Table. The form will help a claim administrator collect the information required to file a first report of injury from the employer.

Please note that the form C-2F will also be used by political subdivisions to report an injury/illness for volunteer ambulance workers and volunteer firefighters. Forms C-2, VAW-2, and VF-2 are now obsolete as all claim administrators have successfully transitioned to eClaims.

Fire Districts of New York Mutual Ins. Co., FDM Preferred Ins. Co. and Fire Districts Ins. Co. went live filing electronically with the WCB on October 7, 2013, therefore please send FDM the completed C-2F form.

If you have any questions regarding this implementation, please free to contact Lenore Pearson-Vouitsis, Claims Manager by phone (888) 314-3004 x 7021 or e-mail Lpearson-vouitsis@fdmny.com.

Any oral or Written communication received from a medical provider, attorney, claimant or other person regarding a claim should be referred immediately to FDM.

Injured volunteers are free to choose physicians, chiropractors, podiatrists or other health care providers. If the volunteer wishes, he/she may sign a waiver and permit the fire district to select an authorized health care provider. In order to avoid unnecessary delays, we recommend one seeks the services of a health care provider who will accept Worker's Compensation rates.

The following is a list of items that FDM needs in support of a claim to guarantee timely payments:

If a C-2F is filed, we will need the following items to support payment of claims:

  • - An initial report from the doctor should be sent within 48 hours of treating the injury (form C-4/48 from doctors, C-48p forms used by podiatrists, C-5 for eye doctors). This is provided by the doctor who first treated the injury. Often this is an emergency room doctor.
  • - Seventeen days after the initial report a progress report (form C-4/48) is needed from the claimants attending physician.
  • - Reports from the attending physician should follow every 45 days (form C-4/48) thereafter.
  • - FDM will also require any medical information relating to a claim to support payments. This could include doctor's notes, post-operative reports, emergency room notes. etc.
  • - Anything that a claimant might need such as a brace, etc. would require a prescription from the claimants doctor. Authorization by FDM is required for specialist consultations, surgical operations or physiotherapeutic procedures. X-rays costing more than $1,000, laboratory test costing more that $1,000, and surgical or other appliances or dental treatments must also be requested via written request or by phone. If done by phone, it must also be followed up in writing.
  • - Anytime a claimant is prescribed medication by their doctor, and the claimant wishes to be reimbursed, the original receipt from the pharmacy must be submitted.
  • - Additional information may be requested, such as a copy of the district's minutes that sanction an event as official or a copy of the log book for a particular event to prove the claimant's attendance. Likewise, it is possible that FDM would request information from a witness of an event. The district will be notified is such information is required.

If a VF-3 or a C-3 is filed for lost time from work, FDM will need the following supportive information:

  • - In addition to the medical information listed above, FDM will also need a letter form the claimant's employer stating when he/she left work. If the claimant has already returned, then the date of return should also be included. This can also be accomplished verbally, but it must be followed up in writing.
  • - Before any indemnity payments (payments for lost time from work) can be sent, FDM must have supporting medical evidence of a disability from the claimant's doctor. This is usually included within the doctor's report (form C-4/48)
  • - FDM may also require a claimant to attend an independent medical exam. This enables FDM to receive an independent evaluation of the claimant's medical situation.

Note:
The above list of items are the basic items that Fire Districts of New York Mutual Insurance Company, Inc. looks for in support of a claim. It is not meant to be an all inclusive list, but rather a general guideline of the items that are needed. Other items may be necessary to support a claim. The claimant and/or the district will be notified.

When your volunteer is injured in the Line of Duty, no one provides better service than us ... NO ONE