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Get NY A-9C 2012-2024

(If Known) CLAIMANT CARRIER CASE NO. (If Known) NAME DATE OF INJURY NATURE OF INJURY OR ILLNESS ADDRESS INJURED PERSON’S SOC. SEC. NO. APT. NO. EMPLOYER INSURANCE CARRIER You may become responsible for the medical costs of treatment for your illness or condition with the provider listed below if (1) you fail to prosecute the claim for workers’ compensation or (2) it is determined by the Workers’ Compensation Board that the illness or condition which required treatment was not.

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