Get Ny C-22 2011-2025
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How to fill out the NY C-22 online
The NY C-22 form is an essential document used for applying for approval of a non-schedule adjustment in workers' compensation cases. This guide will provide clear, step-by-step instructions for completing this form online, ensuring that users understand each component required for a successful submission.
Follow the steps to fill out the NY C-22 form effectively.
- Use the ‘Get Form’ button to access the NY C-22 form and open it in your online editor.
- Begin by indicating the specific law sections applicable to your claim by checking the relevant boxes regarding Section 15, Subdivision 5-b, Workers' Compensation Law, or the Volunteer Firefighters' or Ambulance Workers' Benefit Law.
- Fill in the claimant's Social Security number, W.C.B. case number, and carrier case number in the designated fields.
- Provide details about the district office of hearing, the carrier, and the corresponding employer along with relevant identification.
- Input key dates such as the date of the accident and the date of application, alongside the claimant's date of birth.
- List all sources of income for the claimant excluding workers' compensation benefits and provide each amount accurately.
- Indicate the number and birth dates of any dependents that rely on the claimant for support.
- Answer marriage status and, if applicable, provide the spouse's employment information and weekly earnings.
- State the amount of monthly rent or mortgage and list the first date of employment.
- Include the total compensation paid to date, the last award period and amount, and any therapeutic reports required for submissions.
- Ensure that all questions are answered and check for any pending issues before the Workers' Compensation Law Judge.
- Read through and confirm understanding of key statements regarding the implications of case closure and responsibilities for future medical bills.
- Review the notes at the end of the application for verification requirements, especially for those not residing in New York State.
- Once completed, ensure all signatures are obtained from all parties involved and submit the form directly to the designated Workers' Compensation Board address.
Complete your NY C-22 form online today to streamline your workers' compensation claim process.
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