Source: https://advantagefinancialservice.com/worker_compensation_ny_
Timestamp: 2019-10-19 22:07:43
Document Index: 721675749

Matched Legal Cases: ['§57', '§220', '§57', '§220', '§57', '§125', '§57', '§220', '§125', '§15', '§15', '§25', '§ 688', '§ 27', '§ 2', '§ 13', '§ 23', '§224', '§ 110', '§15', '§32', '§ 2', '§ 13', '§ 2', '§ 15', '§ 15', '§ 11', '§ 25', '§ 51', '§ 2', '§ 20', '§ 901', '§15', '§ 13', '§ 18', '§ 2', '§ 35', '§15', '§15', '§ 9', '§ 15', '§13', '§ 16', '§ 22', '§15', '§10', '§10', '§ 15', '§ 10', '§ 10', '§ 15', '§ 15', '§ 32', '§ 32', '§ 50', '§ 211', '§ 15', '§ 25', '§ 15', '§ 25', '§ 26', '§ 107', '§ 214', '§ 319', '§ 15', '§ 25', '§ 119', '§ 20', '§ 26', '§ 14', '§ 2', '§ 201', '§ 12', '§ 204', '§ 211', '§ 43', '§15']

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Businesses and other parties applying for a government permit, license or contract must prove compliance with New York state workers’ compensation and disability benefits requirements. This manual explains the forms and processes necessary to move those applications through the process, and to stay in compliance with the law.
This document is solely provided for informational purposes. Only the New York State Workers' Compensation Board is authorized to determine entitlement to benefits, based on its application of the law to the specific facts of a case.Prove It to Move It New York State Workers' Compensation Board -- December, 2011 2
The Prove It to Move It Program.................................................................................................... 4
Form CE-200 – Affidavit of Exemption................................................................................. 4
Other Important Highlights of the Prove It to Move It Program............................................ 5
Workers’ Compensation Requirements under Workers’ Compensation Law §57..................... 6
Disability Benefits Requirements under Workers’ Compensation Law §220(8) ....................... 6
WCL §57. Restriction on issue of permits and the entering into contracts unless compensation is secured. ............................................................................................................ 7
DISABILITY REQUIREMENTS .................................................................................................. 7
WCL §220. Subd. 8 .................................................................................................................... 7
Identifying an Independent Contractor ....................................................................................... 8
Workers’ Compensation and Disability Benefits Coverage Requirements for Members of Religious Organizations.............................................................................................................. 8
Workers’ Compensation Coverage Requirements for Religious Organizations ........................ 8
STATE & MUNICIPAL AGENCY COMPLIANCE WITH WCL §57...................................... 10
Section 57: Restriction on Issue of Permits and the Entering of Contracts unless Compensation Is Secured.................................................................................................................................. 10
Local Board Contacts for Government Officials .................................................................. 10
Instructions for Form CE-200 (12/08) .................................................................................. 11
Instructions for Obtaining Form CE-200.............................................................................. 13
Form CE-200 ........................................................................................................................ 14
Form C-105.2........................................................................................................................ 16
Instructions for Form U-26.3 – Certificate of NY Workers’ Compensation Insurance from the New York State Insurance Fund ..................................................................................... 17
Form U-26.3.......................................................................................................................... 18
Instructions for Form SI-12 -- Certificate of Workers’ Compensation Self- Insurance ....... 19
Form SI-12............................................................................................................................ 20
Form GSI-105.2 .................................................................................................................... 22
State Agency Letter from the NYS Department of Civil Service......................................... 24
Ascertaining Violations of the Law...................................................................................... 25
Personal Accountability........................................................................................................ 25
Liability for Claims Incurred by an Uninsured Employer for Workers’ Compensation Insurance -- Section 26-a of the Workers Compensation Law............................................. 25
Penalties for Noncompliance with Workers’ Compensation Mandatory Coverage Requirements ........................................................................................................................ 25
Additional Liability for Uninsured Employers ..................................................................... 26
STATE & MUNICIPAL AGENCY COMPLIANCE WITH....................................................... 27
GENERAL MUNICIPAL LAW §125.......................................................................................... 27
Form BP-1............................................................................................................................. 30
GOVERNMENT AGENCY COMPLIANCE WITH DISABILITY BENEFITS ...................- 32 -
Section 220 (8): Restriction on Issue of Permits and the Entering of Contracts Unless Disability Benefits Coverage Is Secured ..............................................................................- 32 -
Instructions for Form CE-200 (12/08) ..............................................................................- 33 -
Form CE-200 ....................................................................................................................- 34 -
FORM DB-120.1 ..............................................................................................................- 36 -Prove It to Move It New York State Workers' Compensation Board -- December, 2011 3
Instructions for Form DB-155 -- Certificate of NY Disability Benefits Self-Insurance ..- 37 -
FORM DB-155 .................................................................................................................- 38 -
Instructions for State Agency Letter from the NYS Department of Civil Service ...........- 39 -
Letter from the NYS Department of Civil Service ...........................................................- 40 -
Summary: WCL Sec. 57 & 220 (8), and General Municipal Law Sec. 125.........................- 41 -Prove It to Move It New York State Workers' Compensation Board -- December, 2011 4
This instruction manual, Prove It to Move It, will further clarify the requirements. Under the Prove It to Move It program, applicants must prove compliance with NYS workers’ compensation and disability benefits requirements to move their government permit, license or contract along the approval process. This program reflects requirements under Workers’ Compensation Law §57 and §220(8), and General Municipal Law §125. The Prove It to Move It instruction manual formally names the program that has been in place, by statute, since 1922. Nothing has changed in enforcing this program since the last instruction manual was issued in December, 2008. However, based on requests from government agencies, this manual reflects more comprehensive instructions on the program’s requirements.
The reason that a business is exempt from workers’ compensation and/or disability benefits will be clearly stated on Form CE-200. Based on their knowledge of the applicant’s business, government agencies must verify that the business is eligible for the workers’ compensation and/or disability benefits exemption reason described on the CE-200, and notify the Board’s investigative staff if there are discrepancies. Phone numbers for Board investigative staff are located on page 10 of the instruction manual.Prove It to Move It New York State Workers' Compensation Board -- December, 2011 5
Please notify the permit-issuing, license-issuing and contract-making agencies or departments within your jurisdiction of these requirements so that they may comply with the Workers’ Compensation Law. If you have any questions or require additional information, please call the Board at (518) 486-6307. Prove It to Move It New York State Workers' Compensation Board -- December, 2011 6
To assist State and municipal entities in enforcing WCL Section 57, businesses requesting permits or licenses, or seeking to enter into contracts MUST provide ONE of the following forms to the government entity issuing the permit or entering into a contract:
A) Form CE-200, Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage;
C) Form SI-12, Certificate of Workers’ Compensation Self-Insurance (the business calls the Board’s Self-Insurance Office at 518-402-0247), or GSI-105.2, Certificate of Participation in Worker’s Compensation Group Self-Insurance (the business’s Group Self-Insurance Administrator will send this form to the government entity upon request).
A) CE-200, Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage (see above);
Please note that for building permits only, certain homeowners of 1, 2, 3 or 4 family owner-occupied residences serving as their own General Contractor may be eligible to file Form BP-1 (The homeowner obtains this form from either the Building Department or on the Board’s website, http://www.wcb.ny.gov/content/main/forms/bp-1.pdf) Prove It to Move It New York State Workers' Compensation Board -- December, 2011 7
(b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article.Prove It to Move It New York State Workers' Compensation Board -- December, 2011 8
Example 1 -- A trucking company is getting a government contract. The drivers of the trucks that the trucking company is using to fulfill the contract are NOT independent contractors. If the drivers were truly independent, each driver would be contracting separately with the government agency. In this example, the business hiring the drivers CAN NOT submit a CE-200 exemption form. (See page 11.)
Example 3 -- A municipality is issuing a building permit and a separate electrical permit for a job site. The contractor getting the building permit is a sole proproietor doing all the work on the jobsite himself except for the electrical work. When a municipality issues separate building permits and electrical permits, for purposes of Workers’ Compensation Law Section 57,a general contractor obtaining the building permit does not have to count the electrician as a subcontractor since the electrician is working under his/her own operating authority and is thereby, an independent contractor. In this example, the sole proprietor CAN submit a CE-200 exemption form since the electrician is a true independent contractor and not a subcontractor. (See page 11.)
To be exempt, clergy must only perform religious duties, and the teachers must only perform teaching duties. Manual labor includes, but is not limited to, tasks such as filing; carrying materials (e.g., Prove It to Move It New York State Workers' Compensation Board -- December, 2011 9
For more information, see The Employers Handbook, available at: http://www.wcb.ny.gov/content/main/Employers/EmployerHandbook.pdfProve It to Move It New York State Workers' Compensation Board -- December, 2011 10
a) CE-200, Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage;
c) SI-12, Certificate of Workers’ Compensation Self-Insurance (the business calls the Board’s Self-Insurance Office at 518-402-0247), or GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance. A group self-insurance administrator will send this form to the government entity upon request.
Please call the Board at (518) 486-6307 with any general questions regarding Section 57 of the workers’ compensation law.Prove It to Move It New York State Workers' Compensation Board -- December, 2011 11
Form CE-200, Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage
IMPORTANT: These certificates cannot be used to waive the workers' compensation rights or obligations of any party. The applicant may NOT use this certificate to show either another business or that business’s insurance carrier that such insurance is not required.
If appropriate, the applicant requesting a permit, license or contract from a government entity must complete Form CE-200, print a copy of it, sign it and give it to the government entity issuing the permit, license or contract.
5. Each CE-200 will have a certificate number printed on it. Government agencies should verify if the CE-200 provided by the applicant was actually issued by the Workers’ Compensation Board. To verify a certificate of exemption, access the CE-200 application on the Board's website at: www.wcb.ny.gov. Click on the button entitled “WC/DB Exemptions Form CE-200” (In bright yellow letters). Click Verify WC/DB Exemption (Form CE-200), follow the prompts. The following is the hyperlink to the Verify Exemption Certificates (Form CE-200).
Prove It to Move It New York State Workers' Compensation Board -- December, 2011 12
Please remember that applicants are submitting the CE-200 under penalty of perjury, a felony carrying a penalty of four years of jail time. Applicants are attesting that the information contained in the CE-200 is accurate – the Board does not initially verify this information. However, the Board may investigate entities using this certificate to claim exemption from the coverage requirements of the Law. Any false statement, misrepresentation or concealment will subject business owners to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws.
Applicants without access to a computer may obtain a paper application by writing or visiting any Workers’ Compensation Board district office, or by calling 866-298-7830. Applicants are strongly encouraged to use the Board’s electronic web program since they can receive their Form CE-200 immediately, whereas the manual paper filing may take up to four weeks to process. Once the applicant receives the CE-200, the applicant can then submit that CE-200 to the government agency from which he/she is getting the permit, license or contract. This delay results from Workers’ Compensation Board staff having to manually enter information from the applicant’s paper application into the web based application. Accordingly, to avoid delays, all applicants for exemptions are strongly encouraged to use the on-line Form CE-200 on the Board’s website, www.wcb.ny.gov. Click on the button entitled “WC/DB Exemptions Form CE-200” (In bright yellow letters).Prove It to Move It New York State Workers' Compensation Board -- December, 2011 13
If the applicant is having difficulty in printing the CE-200, please call the Board’s CE-200 Hotline at 866-546-9322, then press 1 and then press 3, and leave a voice message with the certificate number, the name of the business and a contact phone number. The CE-200 will be sent to the business address on the CE-200 within one business day.Prove It to Move It New York State Workers' Compensation Board -- December, 2011 14
Form CE-200Prove It to Move It New York State Workers' Compensation Board -- December, 2011 15
Instructions for Form C-105.2 -- Certificate of NY Workers’ Compensation Insurance from Private Insurance Carriers
5. Form C-105.2 can be required by government agencies and by private businesses to show proof of New York workers' compensation insurance coverage.
7. Unless the insurer notifies the government agency (listed as the certificate holder in Box 2 on the C-105.2) that the policy has been cancelled, the C-105.2 is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box “3c".
14. Coverage contained on the certificates may be verified. To verify a Certificate of Insurance, visit the Board's website: www.wcb.ny.gov. Go to the blue question mark at the bottom of the page (Does Employer Have Coverage). Enter the information and see if the coverage matches. If coverage does not match, please call 518-486-6307.
Prove It to Move It New York State Workers' Compensation Board -- December, 2011 16
Form C-105.2Prove It to Move It New York State Workers' Compensation Board -- December, 2011 17
Prove It to Move It New York State Workers' Compensation Board -- December, 2011 18
Form U-26.3Prove It to Move It New York State Workers' Compensation Board -- December, 2011 19
Instructions for Form SI-12 -- Certificate of Workers’ Compensation Self- Insurance
2. Form SI-12 is only issued by the Self-Insurance Office of the NYS Workers’ Compensation Board. Insurance brokers and insurance agents are not authorized to issue it. Only legal entities that are authorized by the Workers’ Compensation Board as fully self-insured are eligible for Form SI-12.
4. Form SI-12 can be required by government agencies and by private businesses to show proof of New York workers' compensation insurance coverage.
10. Coverage contained on the certificates may be verified. To verify a SI-12 go to the Board's website: www.wcb.ny.gov. Go to the blue question mark at the bottom of the page (Does Employer Have Coverage). Enter the information and see if the coverage matches. If coverage does not match, please call 518-486-6307.
Prove It to Move It New York State Workers' Compensation Board -- December, 2011 20
Form SI-12Prove It to Move It New York State Workers' Compensation Board -- December, 2011 21
Instructions for Form GSI-105.2 -- Certificate of Participation in New York State Workers’ Compensation Group Self-Insurance
4. Form GSI-105.2 can be required by government agencies and by private businesses to show proof of New York workers' compensation insurance coverage.
13. Coverage contained on the certificates may be verified. To verify a Certificate of Insurance, go to the Board's website: www.wcb.ny.gov. Go to the blue question mark at the bottom of the page (Does Employer Have Coverage). Enter the information and see if the coverage matches. If coverage does not match, please call 518-486-6307.
Prove It to Move It New York State Workers' Compensation Board -- December,
The primary components in determining workers' compensation premium are classification code and remuneration. While these items are the basis of premium, there are a number of additional components used to determine workers' compensation premium. These additional components enable NYSIF to tailor the workers' compensation premium to suit the individual character of each employer.
The first step in determining proper premium for any business is to identify the correct classification code. Classification codes group together businesses of similar types to ensure that business types with a low potential for loss do not pay the same rate as those with a high potential for loss. The classification system designates which types of work pose more risk to the employees performing the tasks. Businesses are classified according to the operations they perform. The main classification, called the governing code, is assigned to the business as a whole. Employers should remember that it is the company's line of business that determines the workers' compensation classification, not the various jobs within that company.
Remuneration is the basis upon which most workers' compensation premiums are based. Remuneration consists of gross wages, or other compensation, before withholding taxes or other deductions including:
Payments for salary reduction, employee savings plans, retirement or cafeteria plans that are made through employee authorized salary deductions from the employee's gross pay;
Payment for filming of commercials, excluding subsequent residuals that are earned by the commercial's participant(s) each time the commercial appears in print or is broadcast.
The most significant adjustment program in workers' compensation insurance is the Experience Rating Plan. The Experience Rating Plan recognizes that similar employers may not be similar with respect to safety and losses. The Experience Rating Plan adjusts for those differences by modifying the overall premium paid by the employer. The Experience Rating Plan is administered by the New York Compensation Insurance Rating Board (NYCIRB), which promulgates an experience modification for all qualified employers.
Generally, all employers with premiums in excess of $5,000 become "experience rated" by NYCIRB. The experience modification is determined by comparing an employer's actual losses to the expected losses for an employer of similar size in the same industry. This statistical comparison results in the calculation of the experience modification, which is a percentage credit or debit applied to the employer's manual premium.
NYSIF may apply its own modification of rates by means of a surcharge (differential) or credit (discount), in an attempt to tailor the workers' compensation premium to suit the individual character of each employer. NYSIF's modification of rates may be based upon criteria such as:
Compliance with all obligations imposed upon you by the Workers' Compensation Law, including cooperation on claims matters and premium audits.
The New York Compensation Insurance Rating Board (NYCIRB) determines the assessment percentage and may change each time there is a general rate revision. This charge covers the costs of operating the Workers' Compensation Board and special funds such as the Reopened Case Fund, Special Disability Fund and the Special Funds Conservation Committee, as prescribed by law. Effective October 1, 2005, the assessment charge is 17.5%.
New York Workers' Compensation Domestic Terrorism and Catastrophe Premium
The New York Compensation Insurance Rating Board's Rates Committee has adopted, with the approval of the New York State Insurance Department, a change to the manner in which the premium for domestic terrorism and other catastrophes is charged. Effective October 1, 2005 for new and renewal policies, the domestic terrorism and catastrophe element was removed from the manual rates and replaced by a stand alone charge that is similar in operation to the TRIA charge for foreign terrorism.
§15-8 is a section of the NYS WC law relating to disability following previous permanent physical impairment. §15-8 no longer applies for loss dates after June 30, 2007.
§25-A is a section of the NYS WC law that applies to cases closed (NFA), in which the date of accident is more than seven (7) years ago, and in which the date of the last indemnity payment is more than three (3) years ago. If the WCB establishes 25-A, then medical and indemnity payments will be made by Special Funds Conservation Committee, and not the employer or insurance carrier.
An "A-Rated Classification" is a classification with no predefined manual rate shown in the rate pages of the NYCIRB Manual.
The Merchant Marine Act of 1920 also known as the Jones Act (46 U.S. Code, § 688). This federal law, which is part of Admiralty Law, provides that masters and members of crews of vessels have the right to sue their employers for damages in Admiralty Courts for injuries sustained in the course of employment.
The New York State Workers' Compensation Board Advocate for Business assists employers by resolving problems and answering questions about the New York State workers' compensation system.
The New York State Workers' Compensation Board Advocate for Injured Workers accepts complaints concerning matters related to workers' compensation, and investigates and attempts to resolve them. In addition, the Advocate provides information to injured workers to enable them to protect their rights in the workers' compensation system.
A trust fund established in 1935, under NYS WC law § 27, entrusting NYSIF as the administrator for the Trust to assure payment of workers' compensation in claims involving permanent partial disability, permanent total disability, the loss of major members (limbs or eyes) and fatal injuries.
A proportionate division of all or part of the liability in a case between two or more sources of disability for the same claimant. Apportionment can involve another NYSIF case, another carrier's case, or a prior existing medical condition of the claimant.
Two necessary conditions that must be met to establish a work-connected accidental injury. (WC law § 2, Subd. 7)
See: insured
New York State licensed physician authorized by the WCB Chair to render medical care or treatment under the WC law. (WC law § 13-b, Subd. 2)
An individual or company whom the assured or applicant selects (in writing) to act as that assured's agent. Some common examples of an authorized representative are an insurance broker, an insurance agent, an attorney and an accountant. When the assured is in a Safety Group, the Group Manager automatically becomes the assured's representative.
Where a WCLJ's decision is disputed, the aggrieved party may file an application for a review. (WC Law § 23, §224 and Board Rule 13)
The premium rates as defined by the New York Compensation Insurance Rating Board without any modification by a NYSIF discount or surcharge.
See: Insurance Broker
WCB prescribed form "Notice of Compliance, WC Law" informs employees at their place of employment of their rights under the WC law. Employers must obtain this form from their insurance carrier or licensed agent.
WCB prescribed form "Employer's request for reimbursement"
WCB prescribed form "Employer's Report of Injured Employee's Change in Employment Status resulting From Injury"
WCB prescribed form "Employers' Report of Work-Related Accident/Occupational Disease" filed by employers within 10 days after an accident occurs, as required by WC law § 110.
WCB prescribed form "Employer's Statement of Wage Earnings (Preceding Date of Accident)" used to determine the claimant's average weekly wage.
WCB prescribed form "Notice of Claim for Reimbursement Out of Special Disability Fund Under WC law §15-8." A carrier cannot file a C-250 on cases with accident dates after June 30, 2007.
WCB prescribed form "Medical Proof of Change in Condition in Support of Application for Reopening," filed in a closed case to show change in medical condition supporting the reopening of a claim.
WCB prescribed form "Employee's Claim for Compensation" that should be completed by the injured worker and submitted to the WCB within two years of the accident or onset date. The C-3 form contains much of the same information as the C-2.
WCB prescribed form "Settlement Agreement for WC law §32"
"Attending Doctor's Report and Carrier/Employer billing form" provides information about claimant identification, injury history, diagnosis, treatment, disability, causal relation of accident to disability, and degree of impairment. The form includes procedures performed and billing charges. The form is to be filed by the doctor within two days of initial treatment, with additional reports during continued treatment, including a final report. http://www.wcb.state.ny.us/content/main/Forms.jsp
WCB prescribed form "Notice That Right to Compensation is Controverted." If a carrier or self-insured employer is challenging a claim, they must file on or before the 18th day after disability or within 10 days after the employer first had knowledge of the alleged injury, whichever period is greater.
WCB prescribed form "Notice of Treatment Issue/Disputed Bills" used to deny authorization for medical services or treatment and to object to a medical bill on the basis of necessity, causal relationship or other issues to be adjudicated by a WCLJ.
C-8 or C-8.6
WCB prescribed form "Notice That Payment of Compensation has been Stopped or Modified." This notice must be filed by the insurance carrier or self-insured employer within 16 days after the date on which benefit payments were stopped or modified. C-8 is for Indemnity Benefits, and C-8.6 is for Death Benefits.
A unique identifier assigned by the insurance company at the time a case is created for a work-related injury or illness. This number is different than the WCB case number.
The connection between the claimant's injury or illness and the work-related accident or disease. (WC law § 2, Subd. 7)
Disability Certificate of Insurance
Safety and health staff designated as New York State Certified Safety Consultants (CSC) by the New York State Department of Labor. This credential can be used only by those persons who have qualified for and been issued a verification under the Workplace Safety and Loss Prevention Program (Industrial Code Rule 59, NYS Workers' Compensation Law).
The schedule established by the WCB with charges and fees for chiropractic treatment and care furnished to workers' compensation claimants. (WC law § 13-1)
A uniform claim form created by the Centers for Medicare & Medicaid Services (CMS) used to bill for medical service rendered. (Formerly known as form HCFA-1500)
A WCB process established to resolve, in an expeditious and informal manner (e.g. through meeting or telephone conferences), issues involving non-contested claims in which the expected duration of benefits is 52 weeks or less. Failure to reach an agreement through the conciliation process results in the case being scheduled for a hearing.
If a claimant has more than one job, the compensation rate is calculated by adding the wages from all of the claimant's jobs.
A second accident resulting from a prior accidental injury which arose out of and in the course of employment. (WC law § 2, Subd. 7)
(Current Procedural Terminology) The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.
Awarded by the WCB when the death of a claimant is causally related to the accident that initiated the claim. Benefits are payable in order of priority to: surviving spouse, then children, then all others with equal priority such as dependent parents, grandparents, grandchildren, brothers and sisters. Dependency is determined as of the date of the accident.
Department of Insurance (NYS)
The Department of Insurance is responsible for supervising and regulating all insurance business in New York State.
Rates used which are different from those issued by a rating bureau (e.g. New York Compensation Insurance Rating Board)
New York State disability benefits insurance provides temporary cash benefits paid to an eligible wage earner when he/she is disabled by an off the job illness or injury, and for disabilities arising from pregnancies. Employers with one or more employees are subject to the provisions of the New York State Disability Benefits Law. The Disability Benefits Law provides weekly cash benefits to replace, in part, wages lost due to illness or injury that do not arise out of or in the course of employment. Disability benefits include cash payments only. Medical care is the responsibility of the claimant. Medical care is not paid for by the employer or insurance carrier.
Disability insurance rates are determined by each insurer and approved by the Superintendent of Insurance. Currently, NYSIF rates are .20 cents per male employee and .40 cents per female employee, per $100 of payroll to a maximum weekly payroll of $340 per employee.
Disability which allows a claimant to engage in some kind of gainful employment. The difference between the claimant's pre-accident earnings and post-accident earnings is determinative of the reduced earnings rate. (WC law § 15, Sub.5, 5-a)
Disability which precludes a claimant from earning any wages. (WC law § 15, Sub.1,2)
Employer's First Report of Injury via the Internet. eFROI
The responsibility of an employer to reimburse an injured employee for accidents occurring in the course of employment. Such liability is separate from and is in addition to any statutory liability created under Workers' Compensation Law. Employer's liability is usually insured by a separate section (1B) under a workers' compensation policy.
Within the context of a NYSIF safety group, it is a monetary amount above which the remaining cost of a claim is paid by reinsurance or the NYSIF and is not deducted as a loss against a safety group's contingent balance or surplus.
The legislature has established the Workers' Compensation Law as the exclusive remedy of an employee and his /her dependents in a death case, against the employer who has secured workers' compensation. It is the sole recourse that the injured employee, dependents or representatives have against the employer for injuries or death resulting from a work-connected accident or occupational disease. If an employer who is required to secure workers' compensation insurance fails to do so, the employee, if disabled due to a work-connected injury, has the right to elect to either claim workers' compensation or to maintain an action against the uninsured employer for damages. (WC Law § 11)
See Loss Cost Multiplier.
A form of individual risk rating which takes into consideration the loss experience of the particular risk as a credit or a debit to the manual rate for the employer's classification.
An itemization of services provided, amount billed, amount paid, and an explanation of the difference for all payments included in a check (also known as 'draft').
An acronym used in the insurance industry for First Report of Injury.
A fund created under the WC law to assume liability for claims of compensation in certain "stale" cases where specified time limits have elapsed. (WC law § 25a, § 51, Volunteer Firefighters' Benefit Law and Volunteer Ambulance Workers' Benefit Law)
The general employer is the regular or parent employer who makes the employee available to a special employer. The general employer usually exercises indirect control. Either may be liable for the compensation due to the injured employee. (WC law § 2, Sub.3,4)
A premium charged on a prospective basis, fixed or adjustable, or on a specified rating basis, but never on the basis of loss experience. In other words, the cost is guaranteed to the extent that it will not be adjusted based on the loss experience of the insured during the period of coverage. Contrast with Retrospective Rating.
Obsolete form from the Health Care Financing Administration. Updated to a Centers of Medicare and Medicaid Services CMS-1500 Health Insurance Claim Form.
(Healthcare Common Procedural Coding System) HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies.
The WC law provides that "no case shall be closed without notice to all interested parties and without giving to all such parties an opportunity to be heard." These "hearings" are held before a WCLJ who hears and determines claims for compensation for the purpose of ascertaining the substantial rights of the parties. (WC law § 20, 150)
The Health Insurance Portability and Accountability Act of 1996. A law enacted by Congress requiring the U.S. Health and Human Services Department to adopt standards for transmission of information between parties while carrying out financial or administrative activities related to health care. These standards also must address security of protected health information.
An insurance broker is someone licensed to represent an insurance applicant in the negotiating for insurance. Also see: Authorized Representative.
See Workers' Compensation Law Judge
The WCB has jurisdiction over cases with employment in New York State. Notable exclusions from WCB jurisdiction in NYS include: federal government workers and certain employees of local government. Workers covered by separate compensation systems under federal laws (maritime employment, merchant seafarers, interstate railroad employees, etc.) may elect to submit to NYS jurisdiction by waiving their federal rights and remedies.
A partnership formed by two or more persons, having as members one or more general partners and one or more partners limited in his or her obligation for the debts of the firm to the amount of his or her capital contribution and limited in his or her right or power to take part in the control of the business.
Federal law which provides for payments of compensation and other benefits to employees such as longshoreman, harbor workers, and ship repairers. It applies to such employees while working on navigable waters, adjoining piers, and terminals. It does not cover members of a crew of a vessel. U.S. Code (1946), Title 33 § 901-950.
The portion of a premium rate that represents the anticipated costs of claims and associated loss adjustment expenses, including one or more trend factors, but which does not include provisions for insurer-specific expenses such as acquisition costs, overhead and taxes, or profit. Loss costs are based on loss data provided by all workers' compensation insurers and are filed by the rate service organization for workers' compensation (the New York Compensation Insurance Rating Board) with the New York State Insurance Department.
The portion of the premium rate not included in the loss costs filed by the rate service organization for workers' compensation (the New York Compensation Insurance Rating Board), which includes insurer-specific expenses such as acquisition costs, overhead, taxes and profit.
This is the time lost from work directly related to a workers' compensation claim. A claimant is not entitled to lost time wages ( Indemnity Benefits) until after the statutory waiting period of seven (7) days.
A negotiated and WCB approved agreement between a claimant with a non-schedule permanent partial disability and the insurer(s). As a result of the agreement the claimant receives a sum of money representing all future compensation for his/her disability, and the case is considered closed. WC law §15(5-b)
Manual Rate Premium
Premium level charged to a risk under a workers' compensation policy, produced by totaling the product of the classification code rates, by the unit upon which premiums for that code is determined.
The listed premium, stated as dollars per $100 of weekly earnings for each employee, in a state's current schedule; in New York the manual rates are linked to the Classification Code system (i.e., rates are stated for each work classification code used in the state).
Based on medical judgement the claimant has recovered from the work injury to the greatest extent that is expected and no further change in condition is expected. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant.
The schedule established by the WCB Chair of charges and fees for medical treatment and care furnished to workers' compensation claimants. (WC law § 13, Sub. A)
An association of WC insurers which serves as the WC rating organization in about two-thirds of the states. The group establishes standards for use in rate making, develops policy forms, collects statistics, and provides statistical support and services.
An agency within the U.S. Department of Health and Human Services. Part of the Center for Disease Control and Prevention and is generally responsible for conducting research and making recommendations for the prevention of work-related illnesses and injuries.
An association of workers' compensation insurers licensed by the Superintendent of Insurance as the rate service organization (RSO) for workers' compensation in New York. It collects and analyzes loss data and, as the designated RSO, files loss costs with the Insurance Department for rate making purposes. It also administers experience rating and classifications of employers for determining premium. As RSO for workers' compensation, NYCIRB is governed by a board of nine voting members including four representing private insurers writing workers' compensation insurance, one NYSIF representative, a member appointed by the Superintendent of Insurance and one member each, subject to the approval of the Superintendent of Insurance, appointed by the Workers' Compensation Board, the Business Council of New York State, and the New York State AFL-CIO.
A decision of no further action (NFA) is based on a WCLJ determination that no issues need to be adjudicated by the WCB at the time of the finding. If or when further WCB action is required, a hearing must be requested by one of the parties to the claim.
Notice (VFFBL & VAWBL)
Under the Volunteer Firefighters' Benefit Law and the Volunteer Ambulance Workers' Benefit Law, notice of injury or death must be given by the injured volunteer firefighter or ambulance worker or dependents within 90 days after the injury or death.
Employees who are injured on the job must give their employers notice in writing of the occurrence as soon as possible but not later than 30 days thereafter. The WCB may excuse the failure to give notice on the ground that notice for some sufficient reason could not have been given on the ground that the employer had knowledge of the accident or on the ground that the employer had not been prejudiced thereby. In addition, a claim must be filed with the WCB within two years. Failure to file a claim may bar an award of compensation unless the employer has made advance payments to the injured worker or has failed to raise the issue at the first hearing at which all parties were present. (WC law § 18, 28, 40, and 45)
NYSIF's carrier case number also known as a claim number or loss id (e.g. 12345678 - 123 ). The last three numbers is typically the NYSIF claim unit handling this claim.
A disease arising from employment conditions for a class of worker, with the disease occurring as a natural incident for particular occupations, distinct from and exceeding the ordinary hazards and risks of employment. To be considered an occupational disease, there must be some recognizable link between the disease and some distinctive features of the worker's job. (WC law § 2 (15), 3(2), 37)
The claimant (claimant's attorney), employer (employer's representative) , medical provider, carrier and may also be any statutory fund that may be liable in the particular case.
See Prescription Benefits Manager
Part of the employee's wage-earning capacity has been permanently lost on the job. Benefits are payable as long as the partial disability exists, except for schedule loss of use. If there are no reduced earnings as the result of the partial disability, only medical benefits are payable.
Permanent Partial Disability (PPD) Cap
The maximum number of weeks of compensation, from 225 to 525, that a claimant classified as PPD may receive, based on percentage finding of lost earning capacity. The cap applies only to non-scheduled PPD cases with a date of accident on or after March 13, 2007.
Permanent Partial Disability (PPD) Extreme Hardship
An Extreme Hardship redetermination may be made in a capped PPD case where the claimant was classified with a finding of lost earning capacity which exceeds 80%. The claimant may request a reclassification at the WCB for a Permanent Total Disability (PTD) or Total Industrial Disability (TID). (WC Law § 35)
The employee's wage-earning capacity is permanently and totally lost. There is no limit on the number of weeks payable. In certain instances, an employee may continue to engage in business or employment, if his/her wages, combined with the weekly benefit, do not exceed the maximums set by law.
If a case is controverted, the WCB must schedule a pre-hearing conference before a WCLJ judge within 60 days of the receipt of notice of controversy from carrier or employer. This hearing is for the purpose of identifying witnesses, limiting issues and, if possible, to establish the case upon the agreement of the parties
Prescription Benefits Manager (PBM)
Professional Employer Organizations (PEOs) are employee leasing firms that provide long-term or ongoing employee leasing to client businesses. PEOs must be registered with the New York State Department of Labor in accordance with Article 31 of NYS Labor Law.
Broad form of marine liability insurance that covers the operator of a ship for such things as liability to crew members and other individuals on board the vessel, and for damage to fixed objects, such as docks, resulting from the insured's negligence.
In the case of temporary total disability and permanent partial disability both resulting from the same schedule injury, if the period of temporary total disability continues for a longer period than the normal healing period as set forth in WC law §15, Sub. 4-a, the period of temporary total disability in excess of such normal healing period is added to the schedule award. (WC law §15, Sub. 4-a, WC law and § 9, VFBL and VAWBL)
A Rate Service Organization (RSO) is an entity designated by the Superintendent of the New York State Department of Insurance for the collection and analysis of workers' compensation data.
The anniversary rating date is the effective month and day of the policy in effect and each annual anniversary thereafter unless a different date has been established by the Rating Board. Normally the anniversary rating date is the same as the policy effective date. However, the rating date can be different from the policy effective date, e.g., if a policy has been short termed on an experience rated policy for which the rating date remains the same. The rating date determines which rates are to be applied for a given period regardless of the policy anniversary date.
Reduced Earnings (RE)
A compensation rate based on the claimant's reduced earning or reduced earning capacity due to a condition related to a compensable injury (WC law § 15).
The process of restoring injured workers to productive employment through physical means, medical procedures, vocational retraining, selective placement, and social readjustment. Rehabilitation is an integral part of the medical care and other services furnished a claimant under the law. (WC law §13, Sub. a)
An award of two years' compensation paid in a lump sum, to the surviving widow or surviving widower of a fatally injured worker upon his or her remarriage. (WC law § 16, Sub. 2)
A document issued by an insurance company extending the terms of a policy for a subsequent period of time. It reestablishes the in-force status of a policy. All NYSIF policies with in-force status are automatically renewed unless instructed otherwise by the policyholder or their representative.
A case that has been closed by a WCLJ or the WCB, and is subsequently made active again to determine the claimant's eligibility for benefits. (WC law § 22, 23, and 224)
A Return to Work program is a written plan designed to get employees back to work as soon as medically possible following an on-the-job injury or illness, and can be initiated by either the employer or the carrier. It is mutually beneficial to both employees and employers.
An award made by the WCB when the claimant suffers the loss of use of an extremity, sight, hearing, or facial disfigurement, regardless of lost time. A table of scheduled awards, listing body parts and percentage of loss, is used to determine the number of weeks of compensation. (WC law §15, VFBL §10, VAWBL §10)
Permanent physical or functional impairment to an extremity, loss of hearing or sight, or in a facial disfigurement.
The number of weeks of compensation payable for permanent partial disability due to the loss of use of certain members of the body or organs as listed in WC law § 15, VFBL § 10, VAWBL § 10.
Unofficial name for the Special Disability Fund established to encourage employers to hire workers with physical handicaps. When workers with pre-existing conditions suffer further work-related injuries, or disease, that results in a greater disability, the employer, through the insurer, is responsible for only part of the benefits. The Second Injury Fund is responsible for the rest (WC law § 15, Sub. 8). This provision no longer applies for loss dates after June 30, 2007.
Second Injury Law
This law is designed to encourage the employment of people with disabilities by limiting the liability of an employer in the event of the injured worker sustaining a permanent disability due to work connected injury. (WC law § 15, Sub. 8)
WC Law § 32 Waiver Agreement. § 32 waiver agreements allow for complete, full and final resolution of a WC claim.
A method by which an employer or group of employers may secure the payment of workers' compensation or disability benefits for its employees by depositing securities, cash, letters of credit or a surety bond in an amount required by the WCB Chair. (WC law § 50, § 211)
Funds established under the WC law to assure payments of benefits associated with claims, usually by transferring all or part of the liability to Special Funds. (WC law § 15-8, § 25-a, § 15-9, § 25-b, § 26-a, § 107, § 214 and § 319)
The Special Funds Conservation Committee was established in 1938 for the purpose of maintaining and defending the Special Disability Fund and the Fund for Reopened Cases under § 15-8 and § 25-a of the Workers' Compensation Law.
An individual or business firm contracting to perform part of or all of another's contract. See Independent Contractor, General Contractor.
A legal writ commanding a designated person to appear and give testimony at a compensation hearing under penalty for failure to do so. The Chair, Board Members, Judges, officers of the WCB designated by the Chair and any attorney may sign and issue a subpoena, or a subpoena duces tecum, the latter requiring the production of records. (WC law § 119, 142 -3, 231)
A temporary reduced earnings rate of compensation pending adjudication of the actual amount of reduced earnings or the determination of the claimant's reduced wage earning capacity.
When a claimant's work related injury is the result of negligence or wrongdoing of a party other than the employer or a fellow employee, the claimant may sue. A carrier that has paid compensation or disability benefits has a lien on any sums recovered in a third party action. (WC law § 20, 29, 227 and VFBL and VAWBL)
Complete loss of earning capacity due to claimant's permanent partial disability. This is based on medical factors, combined with other vocational factors (such as limited education), which render the claimant incapable of any gainful employment.
A special fund that provides for the payment of workers' compensation in cases where the employer was not insured or self insured. (WC law § 26-a)
VESID (Vocational Educational Services for Individuals with Disabilities)
A division of New York State Education Department providing services for individuals with disabilities. www.vesid.nysed.gov
Volunteer Firefighters' Benefit Law (VFFBL)
WC Law Chapter 64-A provides medical and compensation benefits or, in the case of death, death and survivor benefits to their dependents for volunteer firefighters. (WC law chapter 64 - A)
The wages of a claimant who is under the age of 25 when the accident occurs are presumed to increase under normal conditions. The WCB may consider this fact in establishing the claimant's compensation rate if the injuries are permanent. (WC law § 14, Sub. 5)
The money rate at which employment with an employer is recompensed under the contract of hiring with the employer and shall include the reasonable value of board, rent, housing, lodging or similar advantage received under the contract of hiring. (WC law § 2, Sub. 9, § 201, Sub. 12)
Period covering the first seven days of disability resulting from a work-connected injury or illness. Workers' compensation indemnity benefits are not allowable for the first seven days of disability, except in cases where the disability period exceeds 14 days, indemnity awards are allowed from the date of disability (WC law § 12, § 204 and § 211). There is no waiting period for VAWBL and VFBL cases (WC law § 43, VFBL, and VAWBL).
The 2007 Workers' Compensation Reform Act established a Waiver Agreement Management Office (WAMO) under the supervision of the chair of the Workers' Compensation Board. WAMO will be dedicated to expediting Section 32 Settlements on §15-8 (Second Injury) established cases, pursuant to WC Law.
· determining whether a case should be indexed;
· evaluating claim forms and developing information required by judges for case decisions;
· requesting information (by phone, letter, etc.) needed for case development;
· evaluating whether a compensation case may be processed on an informal calendar;
· referring appropriate cases to the conciliation process; and
· preparing formal notices of decision based on judge's directions.
A state agency, the Workers' Compensation Board administers the provisions of the NYS WC law, including: the Workers' Compensation Law; the Disability Benefits Law; the Volunteer Firefighters' Benefit Law; the Volunteer Ambulance Workers' Benefit Law; and the Workers' Compensation Act for Civil Defense Volunteers on behalf of injured workers and employers.
Workers' Compensation Professional (WCP)
The American Society of Workers' Comp Professionals, Inc., ( AMCOMP) developed an education program, Workers' Compensation Professional (WCP), to help raise professional standards in the field of workers' compensation. The WCP designation signifies that an individual has completed a rigorous workers' compensation curriculum and successfully passed course examinations demonstrating a broad-based knowledge and understanding of workers' compensation.