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VF-2 Instructions PRINT or TYPE Top Section: WCB Case, Carrier Case, & VF Policy = Leave Blank Carrier Code No = 848139 Social Security No = FILL IN 1. Write: Cayuga County, Et al Attn: Payroll, 160 Genesee St, 5th Floor Auburn, NY 13021 2. Your Fire Dept and address 3. Write: NYS Municipal Workers Comp Alliance 333 Earle Ovington Blvd, Ste 505 Uniondale, NY 11553-3624 The Volunteer Firefighter Affidavit of Injury should have most of the data needed to complete the middle section of the VF-2 form. Preparation Section: Date the report A. Name of person filling out the form B. Title and phone of person filling out form C. & D. Leave Blank Note:If the Fire Department suspects an injury did not take place or is being falsely reported as on the job, please put in Section 19, in capital letters: CONTRAVERTED. Contact us and explain the concerns you have with the injury. If you are informed by anyone, or you personally see a vol- unteer firefighter, who is out on workers’ compensation, working someplace else or seen doing something that would be impossible to do with their injury, you have a responsi- bility to report that to the Case Manager. Ex: A volunteer firefighter is out on a back injury and is seen working on a roof, or lifting furniture off a truck. Workers’ Compensation Insurance Fraud is a FELONY. Volunteer Firefighters Workers Compensation Injury Instructions 1. Volunteer - Fill out and sign: Volunteer Firefighter Affidavit of Injury 2. Supervisor - Fill out and sign: VF-2 3. Forward both forms to the County for filing with the carrier: (DO NOT send to the Syracuse address on the back of the VF-2) Fax to: [PHONE REDACTED] - or - Scan and email to: [EMAIL REDACTED] - or - Mail to or Drop off at: Cayuga County Treasurer, Attn: Payroll, 160 Genesee Street, 5th Floor, Auburn, NY 13021 Please also send any other forms or medical bills you receive prior to being assigned a case manager with the carrier. We will forward documents for payment to the carrier. If you have any questions about worker’s comp, please contact us at (315) 253-1481 or [EMAIL REDACTED] Volunteer Firefighter Affidavit of Injury Instructions PRINT or TYPE 1. Fill out the form to the best of your ability - be as complete as possible. Attach any additional sheets as necessary. 2. Submit completed form to your supervisor. Please tell all doctors and hospitals to send all medical reports and bills directly to our carrier. The ID card for our carrier is as below (front & back): Forms Must be filed within 10 days after the injury is incurred or fines and penalties apply that will be charged back to your department.