Procedure for Reporting Workers' Compensation Injury
Volunteer Ambulance Worker
Volunteer Member Responsibilities
- Complete "Volunteer Ambulance Worker's Claim for Benefits" (Form VAW-3) – 1 page
- Complete "Limited Release of Health Information" (Form C-3.3) – 1 page
- Complete "Authorization to Obtain Information" (WC Form 5) – 1 page
* The 3 forms above should be provided to your supervisor immediately.
If your injury requires medical care
This packet contains forms that you will need to take with you to the treating provider & pharmacy.
Take a copy of "Encounter Form" with you to each doctor visit.
Tell your doctor or hospital to send all bills to the following address. Be sure to mark the date of injury clearly on all correspondence.
Warren County Self-Insurance, 1340 State Route 9, Lake George NY 12845
If you require pharmaceuticals for this injury, take the "Pharmacy Benefits" sheet with you to the pharmacy.
Provide your squad supervisor with proper medical documentation if time away from work is recommended.
If your injury requires medical treatment, the Self-Insurance Department will mail you an information packet with your claim information.
Department Supervisor Responsibilities
- Confirm that the member has completed and given you the forms:
- Advise and confirm that the member has retained forms:
- Complete Form C-2F – 1 pages
- Forward the competed Employee forms (3) and the C-2F form to Self-Insurance.
- Notify Self-Insurance when employee returns to work OR if the employee’s condition changes