Get NY C-257 2010
NATURE OF EXPENSE / TIPO DE GASTOS Continue on Reverse. C-257 9-10 SOCIAL SECURITY NO. DATE / FECHA - AMOUNT / CANTIDAD Sigue al dorso. THE WORKERS COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. LA JUNTA DE COMPENSACI N OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR. NYS Workers Compensation Board Centralized Mailing PO Box 5205 Binghamton NY 13902-5205 Statewide Fax Line 877-533-0337 C-257 9-10 Reverse Address for Email Filing wcbclaimsfiling wcb. State of New York WORKERS COMPENSATION BOARD CLAIMANT S RECORD OF MEDICAL AND TRAVEL EXPENSES AND REQUEST FOR REIMBURSEMENT CLAIMANT S NAME WCB CASE NO. RESIDENTIAL ADDRESS In connection with the above workers compensation case you are entitled to be reimbursed for 1 drugs crutches or any apparatus properly prescribed by your doctor and for 2 fares automobile mileage or other necessary expenses going to and from your doctor s office or the hospital* To help you keep a record of such expenses we have provided this form* In order to help insure that you are properly reimbursed list each item of expense below-whether or not you obtained a receipt wherever possible obtain receipts. Submit the completed form and copies of all receipts or bills to the workers compensation insurance carrier or to your employer if self-insured and to the Workers Compensation Board. See Board address on reverse. It is suggested that you retain a copy of the receipts and bills for your records. MAILING ADDRESS IF DIFFERENT En relaci n con el caso de compensaci n para trabajadores antes mencionado usted tiene derecho a recibir un reembolso por 1 medicamentos muletas o cualquier aparato indicado como corresponde por su m dico y 2 tarifas millaje de autom vil u otros gastos necesarios para trasladarse desde y hasta el consultorio de su m dico u hospital* Le proporcionamos este formulario para ayudarlo a llevar un registro de esos gastos. Con el objetivo de garantizar que usted reciba el reembolso correspondiente enumere cada tem de gasto a continuaci n tenga o no un recibo por ese gasto siempre que sea posible intente obtener un recibo. Env e el formulario completo y copias de todos los recibos o facturas a la compa a de seguros de compensaci n para trabajadores o a su empleador en caso de que tenga un seguro propio y a la Junta de Compensaci n para Workers copia de los recibos y facturas para sus registros. State of New York WORKERS COMPENSATION BOARD CLAIMANT S RECORD OF MEDICAL AND TRAVEL EXPENSES AND REQUEST FOR REIMBURSEMENT CLAIMANT S NAME WCB CASE NO. RESIDENTIAL ADDRESS In connection with the above workers compensation case you are entitled to be reimbursed for 1 drugs crutches or any apparatus properly prescribed by your doctor and for 2 fares automobile mileage or other necessary expenses going to and from your doctor s office or the hospital* To help you keep a record of such expenses we have provided this form* In order to help insure that you are properly reimbursed list each item of expense below-whether or not you obtained a receipt wherever possible obtain receipts. .
How It Works
How to fill out and sign c257 online?
Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:
Business, tax, legal and other e-documents require higher of compliance with the law and protection. Our templates are regularly updated according to the latest legislative changes. In addition, with us, all of the information you include in the NY C-257 is well-protected against leakage or damage with the help of top-notch encryption.
The following tips can help you complete NY C-257 quickly and easily:
- Open the template in the full-fledged online editor by hitting Get form.
- Complete the requested boxes that are yellow-colored.
- Press the arrow with the inscription Next to move on from box to box.
- Use the e-autograph tool to e-sign the template.
- Add the relevant date.
- Look through the whole e-document to make sure you haven?t skipped anything important.
- Click Done and save the resulting document.
Our platform allows you to take the entire process of completing legal papers online. For that reason, you save hours (if not days or even weeks) and get rid of extra expenses. From now on, fill out NY C-257 from the comfort of your home, workplace, or even on the move.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Video instructions and help with filling out and completing c257 form
Get your Form filled in and e-signed from the safely at home. This video guide helps you to prepare and manage legal papers remotely.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
USLegal fulfills industry-leading security and compliance standards.
#1 Internet-trusted security seal. Ensures that a website is free of malware attacks.
The highest level of recognition among eCommerce customers.
Guarantees that a business meets BBB accreditation standards in the US and Canada.
Highest customer reviews on one of the most highly-trusted product review platforms.