Get Ny C-64 2011-2025

Filling out the NY C-64 form is essential for documenting the proof of death in workers' compensation cases. This guide provides a detailed and user-friendly approach to completing the form efficiently and accurately.

Follow the steps to properly complete the NY C-64 form online.

1. Click ‘Get Form’ button to access the online version of the NY C-64 form.
2. Begin by entering the WCB case number in the designated field if known. This will help identify the specific case.
3. If applicable, provide the Carrier case number. This information is useful for tracking the insurance aspect of the case.
4. Record the date and time of the accident or injury in the respective fields to establish the timeline of events.
5. Enter the address where the accident or injury occurred accurately. This is crucial for record-keeping.
6. Fill in the name of the deceased person along with their address, date of birth, and Social Security number. These details confirm the identity of the deceased.
7. Specify the employer in the appropriate section, particularly if the claim is associated with a volunteer firefighter or volunteer ambulance worker.
8. Provide details of the insurance carrier, if known, to ensure that the information about the insurance provider is complete.
9. If hospital treatment was involved, enter the name of the hospital, if applicable, to provide further context.
10. Indicate the nearest relative's name and their relationship to the deceased. This information is helpful for future communication.
11. Document the date of death and place of death with complete address details to accurately reflect the circumstances surrounding the death.
12. Select the marital status of the deceased at the time of death from the options provided.
13. Provide comprehensive information about your involvement as a medical advisor for the deceased, including the dates of your first and last visits.
14. In this section, encourage detailing the accident or injury circumstances in the patient's own words, ensuring a firsthand account.
15. Carefully describe the nature and extent of the injury based on your examination, to provide a complete medical report.
16. Clearly state the direct cause of death and assess whether the accident was a contributing factor.
17. Complete the section on contributory causes, if any, to provide a full picture of the circumstances surrounding the death.
18. Indicate if a coroner's inquest was held, along with the name and address of the coroner, if applicable.
19. Ensure your signature is provided on the form as the licensed physician. Include your address and the date of signing.
20. Review all filled sections for accuracy and completeness. Once satisfied, save your changes, download or print the form for your records, and submit it as required.

Complete your NY C-64 form online today to ensure timely processing.