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Get NY ADR-1 2011-2024

This form is to be filed with the Workers' Compensation Board within 10 days of a work-related injury or illness. A copy of this report should be provided to your insurance carrier. No hearing will be scheduled at the Board in response to this report of injury. EMPLOYER'S NAME AND MAILING ADDRESS FILING ENTITY: Employer Carrier INSURANCE CARRIER'S NAME AND MAILING ADDRESS Other (If "Other", give name and address.) CARRIER ID NUMBER CARRIER CASE NUMBER WWC POLICY NUMBER INJURED EMPLOYEE.

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