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SIMPLIFIED INSTRUCTIONS FOR REGISTRATION FORM
Workers' Compensation Registration For Participants In World Trade Center Rescue, Recovery, Or Clean-Up Operations
WHO SHOULD REGISTER
Everyone who performed any type of rescue, recovery, or clean-up work
For any period of time between 9/11/01 and 9/12/02
1. Anywhere in Manhattan south of Canal or Pike Streets, or
2. At the Fresh Kills Landfill, or
3. At the New York City Morgue or the temporary morgues, or
4. On the barges between the west side of Manhattan and the Fresh Kills Landfill.
WHY REGISTRATION IS IMPORTANT
If You Are Not Presently Ill – You Should Register
Thousands of people were exposed to a combination of toxic materials and dust as a result of 9/11. Many have already become ill as a result of the exposure. However, the long-term effects of the exposure are unknown, and people may become ill in the future. You must register in order to protect your right to benefits in the future should you become ill.
If You Presently Have A Workers’ Compensation Case – You Should Register
If you have a workers’ compensation case now, you should still register. Your workers’ compensation claim was filed for one or more medical problems, and those problems may be covered under your existing case. However, if you develop additional medical problems in the future, those problems may not be covered under your existing case. You must register to protect your ability to file an additional claim in the future.
If Your 9/11-Related Workers’ Compensation Case Was Disallowed
If you filed a workers’ compensation claim and it was disallowed because it was not filed in time, you must register before re-filing your claim.
WHEN TO REGISTER
YOU MUST FILL OUT AND FILE A WTC-12 FORM BEFORE AUGUST 14, 2008.
DETAILED INSTRUCTIONS FOR FILLING OUT THE REGISTRATION FORM
YOU MUST FILL OUT A WTC-12 FORM AND FILE IT WITH THE NEW YORK STATE WORKERS' COMPENSATION BOARD TO REGISTER
FILLING OUT THE WTC-12 FORM
Top Of The Form (before the numbered questions)
- Write your name on the line at the top of the form
- On the line to the right of “State of,” write the name of the state where you will be signing the form.
- On the line to the right of “County of,” write the name of the county (or foreign country) where you will be signing the form.
- On the line to the right of “I,” write your name again.
Numbered Questions
1. Fill in your residence address (where you live), your mailing address (where you get your mail), your telephone number, your Social Security Number (optional) and your date of birth.
2. You do not need to do anything about this question.
3. Write either “employee” or “volunteer” on the line. If you were paid by a person or company for rescue, recovery, or clean-up work, write “employee.” Otherwise, write “volunteer.” You can write “both” if indicated.
4. If you were an employee, simply draw a line through this question. If you were a volunteer, list any papers or other items you have that would show that you were a volunteer. Photos, letters, awards, I.D. badges, or any other proof is acceptable.
5. Fill in the boxes in the grid indicating the dates you were involved in rescue, recovery, or clean-up, where you worked on those days, what you did (you may write “rescue work,” “recovery work” or ”clean-up work”), and the name and address of your employer if you were there as an employee. (If you have the wrong address for the employer you will not be disqualified.) If you volunteered through an organization, write the name and address of the organization. If there is no organization that will have a record of you, simply write “volunteer.”
6. If you already filed a claim for workers’ compensation benefits for a 9/11 or World Trade Center injury or illness, write “have” on the first line in this question, the date of your C-3 form (if you know it) on the second line, and your WCB Case number (if you know it) on the third line. If you did not file a claim before, then write “have not” on the first line and leave the rest of the question blank.
7. and 8. You do not need to do anything about these questions.
Bottom Of The Form (below the questions)
- The WTC-12 form must be a sworn statement. This means that you must sign it in front of someone who is a notary public. A notary public is a person authorized to take an oath from you and who can stamp the form indicating that you signed it in front of them. Do not sign the form and bring it to a notary later, because the notary may refuse to stamp your signature if they do not see you sign it. You should bring the completed, but unsigned, form to a notary public and then sign it in front of the notary.
- The notary may charge you a $2 fee to notarize the form for you.
- The notary should fill out the part of the form below your signature, sign it, and stamp it.
You may have the form notarized by an official notary in your country of residence.
WHERE TO FILE THE WTC-12 FORM
- You may bring a copy of the WTC-12 form to any office of the Workers’ Compensation Board. We recommend that you make a copy of the completed and notarized form and that if you bring it to the Board in person you ask the Board to receipt your copy.
- If you mail the form, we again recommend that you keep a copy for your records and that you mail the original certified mail, return receipt requested so that you will have proof that you sent it in. The Board’s mailing address is:
NYS Workers’ Compensation Board
P.O. Box 5205
Binghamton, New York 13902-5205 |
FILING A WTC-12 FORM IS NOT FILING A CLAIM. THE WTC-12 FORM IS ONLY A REGISTRATION FORM, NOT A CLAIM FORM.
IF YOU WISH TO FILE A WORKERS' COMPENSATION CLAIM, READ THE INSTRUCTIONS ON THE NEXT PAGE, FIRST.
FILING A WORKERSí COMPENSATION CLAIM
REGISTRATION IS NOT FILING A CLAIM. THE WTC-12 FORM IS ONLY A REGISTRATION FORM, NOT A CLAIM FORM!
C-3 FORM or WTCVol-3 FORM
If you did rescue, recovery, or clean-up work as an employee, then the C-3 form is the form you need to file a claim. If you were a volunteer, then you should use a WTCVol-3 form. Both forms are available at offices of the Workers’ Compensation Board or online at www.wcb.state.ny.us.
WHO SHOULD FILE A CLAIM
- If you filed a workers’ compensation claim before for illness due to 9/11 or World Trade Center exposure, and if the claim was disallowed because of time limits, you should re-file a C-3 or WTCVol-3 at the same time that you file the WTC-12 registration form.
- If you have an established workers’ compensation claim but not all of your injuries or illnesses have been included in the case, you should re-file a C-3 or WTCVol-3 at the same time that you file the WTC-12 registration form.
- If you are ill because of 9/11 or World Trade Center exposure, but have not previously filed a claim for workers’ compensation benefits, you should re-file a C-3 or WTCVol-3 at the same time that you file the WTC-12 registration form.
- If you are not presently ill, you should not file a C-3 or WTCVol-3 form until you become ill. Should you become ill in the future, you will have two years from the date of your first medical treatment or time missed from work to file.
FOR ANSWERS TO GENERAL QUESTIONS ABOUT FILING A WORKERS’ COMPENSATION CLAIM, CLICK HERE.
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