
OF INJURED (Last Name, First Initial) Date of Accident Weekly Comp. Rate PLEASE TYPE Describe injury and any complications. Give latest medical status, including return to work dates and degree of permanency estimated. Report Valued as of:______________________________________________________ No. of Weeks of Disability Paid to Date Year of Birth Has Claimant Returned to Work (Y/N) & Date *Reserve for Future Payments Comp. Medical For Board Use Only Comp. Medical COMPENSATION AND M.
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How to fill out the NY SI-4.1 online
Filling out the NY SI-4.1 form online can be a straightforward process if you follow the right steps. This guide provides clear instructions to help you complete the Self-Insurer’s Statement of Outstanding Disability Claims accurately and efficiently.
Follow the steps to complete the NY SI-4.1 online.
- Click ‘Get Form’ button to obtain the form and open it in your chosen online document platform.
- Begin by entering the name of the self-insurer in the designated field at the top of the form.
- In the next section, enter the W.C.B. case number associated with the claim.
- Fill in the injured person's name using their last name followed by the first initial in the provided space.
- Record the date of the accident in the specified format, ensuring accuracy for the claim.
- Indicate the weekly compensation rate that applies to the case.
- Type a description of the injury and any complications that have arisen, along with the latest medical status, return-to-work dates, and an estimated degree of permanency.
- Input the report valued date in the designated space.
- Enter the number of weeks of disability that have been paid to date.
- Provide the year of birth for the injured party.
- Indicate whether the claimant has returned to work by selecting Yes or No, and if applicable, include the return date.
- Fill in the reserves for future payments, specifying compensation and medical reserves.
- After filling out all sections, ensure that you sign the form by providing the signature of the company officer of the self-insurer along with their typed name and title.
- Lastly, include a telephone number and address, and indicate the date when the form is signed.
- Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.
Complete your NY SI-4.1 form online today for efficient processing.
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