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-OVER- 1 of 2 CAYUGA COUNTY VOLUNTEER FIREFIGHTER AFFIDAVIT OF INJURY To be filled out by the volunteer within 48 hours of injury (Submit to supervisor in charge at time of injury) 1. Volunteer Name: Social Security Number: Home address: Home phone number: Date of Birth: 2. Regular Employer (Name, Address): _ _ Did you miss any work due to this injury? NO___ YES First date missed: Date Returned to work: Estimated Weekly Wage: Number of Days Worked per Week: Employer Phone: 3. Date of Injury: Time of Injury: Location where injury occurred: Is this a re-injury? NO YES : Date of previous injury: 4. Has this incident been discussed with your Supervisor? NO YES : Name of Supervisor, Date/Time notified: 5. Nature of injury (body parts affected): Was there any visible injury? NO YES : Describe: Describe the injury and the object, person or substance that caused the current injury: Describe in your own words exactly how the injury happened: 6. Was medical care provided? NO YES : If so, when: By Whom: Provider/Doctor (Name/Address/Phone): CIRCLE PART(S) OF BODY AFFECTED: ---PAGE BREAK--- -OVER- 2 of 2 7. Any witnesses to the injury? NO YES : (Please attach witness statements) Name/Address/Phone: Name/Address/Phone: MEDICAL FRAUD DECLARATION: I hereby affirm under the penalties of perjury that the information contained above is true and correct. Volunteer’s Signature: _ Date: INSURANCE FRAUD DECLARATION: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals information for the purpose of misleading, concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. I understand that my signature herein constitutes my affirmation that I am applying for Worker’s Compensation benefits pursuant to law, which I have made not false claims or statements or concealed any material facts in order to receive said benefits and that doing so would make me liable for civil and criminal penalties including jail. Volunteer’s Signature: _ Date: BE SURE TO SIGN BOTH THE MEDICAL AND INSURANCE FRAUD DECLARATION. This report is to be sent by the supervisor with the VF-1 and VF-3 form to: Fax to: [PHONE REDACTED] -or- Scan and email to: [EMAIL REDACTED] -or- Cayuga County Treasurer, Attn: Payroll 160 Genesee Street, 5th Floor, Auburn, NY 13021 Call with any questions: [PHONE REDACTED] Please tell all doctors and hospitals to send all medical reports and bills directly to our carrier. (DO NOT send this form here): New York State Municipal Workers Compensation Alliance 333 Earle Ovington Blvd., Suite 505 Uniondale, NY 11553-3624 (866) 697-6922 (phone); (516) 227-2352 (fax) The volunteer has free choice of doctor or hospital as long as the doctor or hospital is recognized and approved by the Worker’s Compensation Board. The attending Medical Doctor must submit medical reports in accordance with the Worker’s Compensation Law to the N.Y.S. Municipal Workers’ Compensation Alliance. The doctor or other medical providers may not submit bills to collect fees from the employee. The County has the right to have the employee examined by a doctor of their choice at a time/place reasonable to the employee. WORKER’S COMPENSATION BENEFITS WILL NOT BE PAID WITHOUT MEDICAL PROOF OF DISABILITY. Rev 6/13/17