New Claim Submissions
The Board has introduced a new Form C-2F, Employer's First Report of Work-Related Injury/Illness. 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.
If you have any questions regarding this implementation, please contact Lori Vega, Claims Manager by phone 888-314-3004 x 7021 or e-mail [email protected].
CLAIM PROCESS:
Employer must report injury to the WCB and Carrier within 10 days of notice.
To assist in expediting the initial reporting, we have introduced the FDM FastFax Notice of Injury. The district can fax (845-352-2022), or email ([email protected]) 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.
Volunteer Firefighters’ Benefits Law:
GUIDE TO FILING A CLAIM
The Volunteer Firefighters' Benefits Law provides cash benefits and/or medical care for volunteer members who are injured, become ill, or die in the line of duty. Weekly cash benefits and medical care are paid by Fire Districts of New York Mutual Insurance Co., Inc., in accordance with the applicable law. The Workers’ Compensation Board is a New York State agency that administers these laws. If disputes arise, the Board adjudicates them through a judicial proceeding.
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STEP I: 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.
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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. It is the form for volunteer firefighters as well as paid employees and paid firefighters. 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, injury, or illness in which a volunteer firefighter or paid employee requires medical treatment beyond ordinary first aid and medical bills resulting from such treatment. The injured party’s full legal name and social security number must be completed for proper filing.
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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 (volunteers) or C-3 (paid employees).
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 from his/her regular employment.
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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):
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.
NYS Workers’ Compensation Law:
GUIDE TO FILING A CLAIM
Our adjusters help guide claimants through the process when a claim is filed. Depending on the individual circumstances of the claimant’s injury or illness, some additional forms may be required. We are here to assist your injured fire service personnel with the necessary information required by the Workers' Compensation Board.
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C-11
This form is the district’s/employer’s report of an injured employee’s change in status and/or return to work status. This report must be completed each time a paid employee loses time and/or returns to work.
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C-240
This form is the district’s/employer’s statement of wage earnings for 52 weeks preceding the date of accident.
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 one seeks the services of a health care provider who will accept Workers’ Compensation rates.
Medical Care
All medical care for your injury or illness is paid for by your insurer. This care is covered whether or not you lose time from work. It is also paid in addition to any benefits for missed wages.
Health care providers who treat you must be authorized by the Board. You can locate a Medical Provider HERE, or by calling 800-781-2362. You may receive care from any of these providers or from your own doctor if your doctor is Board-authorized.
The health care provider will send the bills directly to the insurer and the Board. You do not to pay any bills unless the Board disallows your claim. If specific medical services are disputed, the insurer must pay any undisputed portion. It must also explain in writing why the services were not paid, and request any information needed to pay them.
Out-of-State Medical Care
If an injured workers resides out of state, and is treated by an out-of-state health care provider the MTGs and all Prior Authorization Review-related requirements and processes apply for out-of-state providers. Please note the MTGs do not change the out-of-state reimbursement methodology. More details on reimbursement on out-of-state care can be found in the Medical Fee Schedule Ground Rules HERE.
Medical Treatment Guidelines
The Workers' Compensation Board has Medical Treatment Guidelines that health care providers are required to use when treating certain injuries.
These guidelines allow the health care provider to perform much of your treatment without needing to ask the insurer for authorization. However, your health care provider may still need to ask for authorization before performing certain tests or procedures.
If you or your health care provider receive a notice that a treatment authorization has been denied, you should read the notice carefully. You or your health care provider may be able to request a review of the denial, giving you the opportunity to present evidence to the Board. The Board will then determine whether the treatment should be authorized.
Death Claims
When an injured worker dies due to a work-related injury or illness, that worker’s dependents (as defined by law) may file a claim to be reimbursed funeral expenses, you should file a Claim for Compensation in Death Case (Form C-62), and the appropriate documentation with the Board. Death claims must be filed within two years of the worker’s death. Immigration status is not a factor, nor is the surviving family's location.
This claim will be processed more quickly if copies of necessary documents are submitted to the Board. Attach copies of the documents which you have in your possession. Otherwise obtain copies and bring them to the first hearing. DO NOT DELAY filing this claim form. Necessary documents are as follows:
- A medical report from doctor who treated the deceased
- Death certificate
- Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc
- Itemized funeral bill
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.
Questions?
If you have any questions regarding the preparation of claim forms, please contact:
Claim Department
1 Blue Hill Plaza
PO Box 1609
Pearl River, NY 10965
Phone: 888-314-3004 | Fax: 845-352-2022