WTC-12 9-16 NYS Workers Compensation Board Centralized Mailing Address P. O. Box 5205 Binghamton N.Y. The registration form WTC-12 must be filed not later than September 11 2018. To register this Sworn Statement must be accurately and truthfully completed and the original filed with the Board District Office or Downstate Central Mailing Center see addresses below not later than September 11 2018. State of New York WORKERS COMPENSATION BOARD REGISTRATION OF PARTICIPATION IN WORLD TRADE CENTER RESCUE RECOVERY AND/OR CLEAN-UP OPERATIONS Sworn Statement Pursuant to Workers Compensation Law 162 Please read the background and instructions below completely and carefully before completing the Sworn Statement beginning on page 3. BACKGROUND On August 14 2006 Workers Compensation Law WCL Article 8-A was enacted to expand the time for a participant in World Trade Center rescue recovery and/or clean-up operations who suffers or may suffer in the future from a qualifying condition to file a claim f....
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How to fill out the NY WTC-12 online
The NY WTC-12 form is essential for individuals who participated in World Trade Center rescue, recovery, or clean-up operations. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to fill out the NY WTC-12 form online.
- Click 'Get Form' button to access the WTC-12 online form and open it in your browser.
- Provide your current residential address, including details like apartment number, street name, city, state, and zip code. If your mailing address differs, include that as well. Ensure you add your phone number. Optionally, provide your Social Security Number and date of birth in the required format.
- Indicate that you participated in the World Trade Center operations within the specified dates, confirming your involvement at one of the designated sites, such as the World Trade Center site or Fresh Kills Land Fill.
- Specify whether you participated as an employee or a volunteer. Clearly indicate your status in this section.
- List any evidence supporting your participation as a volunteer, such as badges, letters, or photographs. If you were not a volunteer, you may leave this section blank.
- Complete the table by providing the dates and locations of your work, along with a brief description of the tasks performed. Include the complete name and address of your employer or volunteer agency, and their insurance carrier if known.
- State whether you have previously filed any workers' compensation claims related to your participation and provide the details if applicable, including the claim's filing date and WCB case number.
- Acknowledge that submitting this statement is not the same as filing a compensation claim. You must file a separate claim using Form C-3 or WTCVol-3 as required.
- Review your completed Sworn Statement to ensure all information is accurate and truthful.
- Sign the Sworn Statement in the presence of a notary public, ensuring your signature is notarized to validate the document.
- Submit the original Sworn Statement to the Workers' Compensation Board at their Centralized Mailing Address before the deadline.
Complete your NY WTC-12 form online today to ensure your registration as a participant.
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