Guide to Filing a Claim


STEP 1: PREPARE A RECORD OF ALL ACCIDENTS.

The law requires all fire districts to keep a record of all injuries sustained by their volunteer firefighters in the line of duty. You should do this by completing a VF‐1 form.

VF‐1: This is not an insurance form, but rather a method of keeping an internal record by your fire district of all accidents. This form should be completed after any accident and held with the District. If a claim for benefits is made at a later date, this form should be submitted with that claim.

NOTE: If a firefighter is exposed to a hazardous substance or hazardous liquid (i.e. AIDS or asbestos) and no medical bills result out of that exposure, but the firefighter would like to have it on record, complete a VF‐1, have an official initial it and keep it on file for future reference. You may also wish to give a copy of the form to the injured/exposed party. It is not required to forward the form to the Insurance Company.

STEP II: REPORT OF ACCIDENT OR INJURY.

In addition to completing a VF‐1, the following forms may be necessary. Report all claims by filing the applicable forms with Fire Districts Mutual. BE SURE THAT ALL FORMS ARE SIGNED BY AN AUTHORIZED REPRESENTATIVE.

C-2F: This is the actual report of loss to the insurance company. We cannot set up a claim unless a signed and completed C-2F is received. Failure to file a C-2F within 10 days is a misdemeanor. Submit this form for any accident or injury in which a volunteer firefighter requires medical treatment beyond ordinary first aid and medical bills resulting from such treatment. The injured party’s social security number must be completed for proper filing.

STEP III: CLAIM FOR BENEFITS FOR LOST TIME FROM WORK.

If a firefighter loses time from work and is due reimbursement, the following form must be filed.

VF‐3: This form must be filed by the injured firefighter, in addition to a C-2F form, if the accident or injury is one in which the volunteer firefighter loses time form his/her regular employment. This form should be filed promptly, but no later than two years from the date of injury.

STEP IV: DEATH CLAIMS.

In a case where a firematic injury should result in the death of a volunteer firefighter, the following form should be filed within 90 days but no later than two years after the death to Fire Districts Mutual and the New York State Workers Compensation Board ( as indicated on the back of the applicable forms) :

VF‐62: This form must be completed by the fire district following the death of a firefighter.

C‐64: This form is for proof of death. It must be completed by the physician last in attendance of the deceased.

C‐65: This form is for proof of burial and funeral expenses. It must be completed by the undertaker.

To assist in expediting the initial reporting, we have introduced the FDM fast fax “Notice of Injury”. The district can fax (845 352-2022) us information to get the claim started, then follow up with the completion of the C-2F form. THE FAST FAX IS NOT IN LIEU OF THE C-2F FORM.

PLEASE NOTE:

If a volunteer firefighter from another fire district volunteers his or her services during an emergency and such services (other than mutual aid) are accepted by the officer in charge, then such firefighter, if he/she is injured in the line of duty, is covered under your districts Volunteer Firefighters’ Benefit Law policy.

Volunteer firefighters of the municipalities responding under mutual aid remain covered under their own jurisdiction and are not the responsibility of the department requesting mutual aid. If a non‐reportable accident later develops into one which requires medical treatment or causes loss of time from employment, then the C- 2Fform should be filed immediately. A copy of your internal report (VF‐1) should also be sent to us. VF‐1 forms should not be sent to the Workers Compensation Board.

If a fire district learns of any new developments regarding a case after the C-2F has been filed, please notify the claim department at Fire Districts of NY Mutual Insurance Co., 777 Chestnut Ridge Road, Suite 302, Chestnut Ridge, New York 10977. If you are doubtful as to whether the cases falls under the provisions of the Volunteer Firefighters’ Benefits Law or if you are suspicious as to the validity of the claim, immediately notify us in writing.

PUBLIC SAFETY OFFICERS’ BENEFIT ACT

In addition to the state benefits under the Volunteer Firefighters Benefit Law, the federal government now provides a death benefit (annually adjusted every October for Consumer Price Index" to the surfing dependents of paid and volunteer firefighters, as well as law enforcement officers, who die from an injury sustained while in the performance of their duties.

These federal benefits come within the scope of the Public Safety Officers’ Benefit Act‐1976 administered by the Law Enforcement Assistance Administration.

Click here psob.gov for information on applications for any paid or volunteer firefighter who dies in the line of duty on or after September 19, 1976.

NEW YORK WORKERS COMPENSATION LAW

This section applies to Fire Commissioners and all paid employees of a fire district including paid firefighters, ambulance workers, secretaries, etc.

STEP I: REPORT ACCIDENT, INJURIES, AND DEATH.
To file a Worker’s Compensation claim, several forms may be necessary. Report claims by filing all applicable forms with Fire Districts Mutual. Be sure that all claim forms are signed by an authorized representative.

C‐2F: This form is the fire district’s report of injury for a paid employee.

C‐3: This form is similar to the VF‐3 form. It is a claim for benefits for lost time from your regular employment and is completed by the injured employee.

C‐11: This form is the fire districts report of an injured employee’s change in employment status resulting from injury. This should also include the employee’s date of return to employment.

C‐240: This form is the fire 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‐2F, which must be filed within 10 days of the injury. The form C‐2F is used to report all injuries.

Fire Commissioners and other fire 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 than $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 payments which begin the day of the injury. The rate is 2/3 of the average weekly salary.

When a paid employee wishes to be compensated for lost time from work due to his/her injury, then form C‐ 3must 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 district should immediately file a form C‐11, an “Employers 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, or if there is an increase or reduction in wages. This form should be prepared as 4 copies, one copy to be sent to the workers compensation Board, two (2) copies to Fire Districts Mutual and one copy kept by the district.

GENERAL INFORMATION

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 on seeks the services of a health care provider who will accept Workers’ 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:

1) An initial report from the doctor should be sent within 48 hours of treating the injury (Form C‐4/48 from doctors, C‐48P and C‐4P 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.

2) Seventeen days after the initial report a progress report (C‐4/48) is needed from the claimants attending physician.

3) Reports (form C‐4/48) from the attending physician should follow every 22 days thereafter.

4) FDM will also require any medical information relating to a claim to support payments. This could include doctors’ notes, post-operative reports, emergency room notes, etc.

5) Anything that a claimant might need such as a brace, etc. would require a prescription from the claimant’s doctor. Authorization by FDM is required for specialists consultations, surgical operations or physiotherapeutic procedures. X‐rays and special diagnostic laboratory tests costing more than $1,000, and surgical or other appliances or dental treatments must also be approved.

6) Any time a claimant is prescribed medication by their doctor, and the claimant wishes to be reimbursed, the original receipt from the pharmacy must be submitted.

7) Additional information may be requested, such as a copy of the district’s minutes that sanctioned 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 if such information is requested.

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

1) In addition to the medical information listed above, FDM will also need a letter from 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.

2) 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 with the doctor’s report (form C‐4/48).

3) 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 is 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 needed to support a claim. The claimant and/or the district will be notified.

HEARINGS

A claimant’s case (depending on the injury) will occasionally come up for a hearing with the Workers’ Compensation Board. If a hearing is scheduled by the Worker’s Compensation Board, FDM will appear on behalf of the district. The district is not required to send any of its commissioners or officers to the hearing unless they are specifically requested to attend by the Worker’s Compensation Board, the Insurance Company, or an attorney. Of course, any member of the Board of Fire Commissioners may attend a hearing at any time.

QUESTIONS ?

If you have any questions regarding the preparation of claim forms, please contact:

Claim Department
Fire Districts of New York Mutual Insurance Co., Inc.
777 Chestnut Ridge Road, Suite 302
Chestnut Ridge, New York 10977
phone 888-314-3004 fax 845-352-2022

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