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Get HIMP-1(1/09) - Workers' Compensation Board - New York State - Wcb Ny

Date of Accident/Injury Claimant's Name WC Carrier Case Number WC Carrier Code Reimbursement Amt. Requested Employer's Name Date Payment Made Date Request for Reimb. Filed Health Insurer's Claim ID No. Name and Address of Workers' Compensation Insurance Carrier/Employer/Special Fund Date of Full Match (If Applicable) Was ANCR Established? q Yes q No Status of Case q Open q Closed Health Insurer's Fed. Tax ID No. Health Insurer's Telephone No. (If previously filed for this case).

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