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STATE OF NEW YORK WORKERS' COMPENSATION BOARD NOTICE TO LIABLE POLITICAL SUBDIVISION OF VOLUNTEER FIREFIGHTER'S INJURY OR DEATH THIIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. THIS NOTICE IS REQUIRED TO BE FILED WITHIN 90 DAYS AFTER THE DATE OF INJURY OR DEATH UNLESS CLAIM FOR BENEFITS, INCLUDING MEDICAL, HOSPITAL OR OTHER CARE, (VF-3 or VF-62) IS FILED WITHIN 90 DAYS AFTER THE DATE OF INJURY OR DEATH. Sec.40 of the Volunteer Firefighters' Benefit Law provides that, unless Claim for Benefits is filed within 90 days after injury or death, Notice of such injury or death shall be given by delivery in person or by registered mail within 90 days by the injured volunteer firefighter or by any person claiming to be entitled to benefits, or by someone in his/her behalf, to the designated officer of the liable political subdivision as follows: If the political subdivision liable for benefits is a Then give to a. County b. City c. Town d. Village e. Fire District a. Clerk of the Board of Supervisors b. Comptroller or Chief Financial Officer c. Town Clerk d. Village Clerk e. Secretary If your injury occured prior to March 1, 1964, the injury should be reported to the county, city, town, village or fire district for which the service was rendered whether such service was rendered for the home area or for another area under contract or in response to a call for assistance. If the injury occured on March 1, 1964 or thereafter, the home county, city, town, village or fire district is liable for thr payment of benefits regardless of whether the injury was incurred while serving your home area or an aided area. If you have any doubt concerning the liable political subdivision, a copy of this notice should be filed with all the political subdivisions involved. THIS NOTICE IS NOT A CLAIM FOR BENEFITS. FAILURE TO FILE THE CLAIM FOR BENEFITS (FORM VF-3 or VF-62) WITHIN TWO YEARS AFTER INJURY OR DEATH MAY BAR YOU FROM RECEIVING BENEFITS. 5. Address and community where injury 6. Date of at_____o'clock____M. Date of Place of 7. State fully nature and cause of injury or VF-1 (8-97) Volunteer Firefighter Signed or Signed A person on his/her behalf, or in case of death, by any one or more of his/her dependents, or by a person on their behalf. Relationship To: Name of Officer Title of Officer Political Subdivision Liable for Benefits 1. VOLUNTEER FIREFIGHTER First Name Middle Initial Last Name Home Address Apt. No. 3. POLITICAL SUBDIVISION OR FIRE DISTRICT 4. REGULAR EMPLOYER, IF ANY 2. FIRE COMPANY Name Address