Please rate Form Rfa 1W 5-22
You may file this form (RFA-1W) and any attachments with the Workers' Compensation Board when you want the Board to take a specific action in your claim.
Copy: you must send a copy of this form to the insurer(s), or directly to the employer or its third party administrator if the employer is self-insured.
Boxes: check all boxes that apply and be sure to attach additional forms, medical reports, letters, etc. as required for each checkbox.
Lawyer: a lawyer cannot charge you directly for representation in a workers' compensation claim.
| Question | Answer |
|---|---|
| Form Name | RFA-1W |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 69 |
| Avg. time to fill out | 12 min |
| Edition | 5-22 |
| Where to send | Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | RFA-1W, RFA 1W, RFA1W, Form RFA-1W, RFA form, Request for Assistance by Injured Worker |
| Official source | RFA-1W (Rev 5-22), |
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