RFA-1W: Request for Assistance by Injured Worker

Claim Information: all communication should include these numbers. Enter the Date of Injury/Illness and the WCB Case #.

This form is not to be used to report an injury. To file a claim, use Form C-3.

Under Injured Worker Information, enter the Last Name, First Name, MI, Mailing Address, Line 2, City, State, Zip Code, Country, Daytime phone #, Email Address, Social Security # and Date of Birth, and mark M, F or X for Gender.

Check if new address.

Providing your social security number to the Board is voluntary.

There is no penalty for failure to provide your social security number on this form; it will not result in a denial of your claim or a reduction in benefits.

Under Employer Information, enter the Employer Name, Mailing Address, Line 2, City, State, Zip Code, Country and Employer Phone.

The Tax ID # is the (check one): SSN or EIN. Enter the Federal Tax ID #.

Box a: I am not working as of __ and not receiving payments. Medical documentation indicating disability required. Check all that apply:

I have filed a claim for a work related injury. My employer is not paying my wages. My claim has not been denied. I have not received a decision barring me from compensation. I have attempted to resolve the issue with the insurer.

Box b: My payments have been stopped or reduced.

Box c: I have returned to work as of __ at full pay.

Box d: I am making less money than I was before I got hurt. Attach current pay stub and medical reports from your doctor.

Box e: I had two or more employers on the date of accident/injury (concurrent employment). Attach weekly gross pay before your injury and statement from second employer regarding lost time.

Box f: I was released from incarceration on __ and am not receiving payments. Attach medical report that shows a medical disability and release from custody papers.

Box g: I have not been paid as directed in the decision filed on __.

Box h: My Prior Authorization Request (PAR) was denied by the insurer. Attach PAR denial.

Box h: Review by WCB Adjudication can only be requested if: Denial category was Administrative or No Jurisdiction, and you attach any documents that show why the denial was incorrect; or MTG Special Services or MTG Variance PAR was denied for Medical reasons; or Non-MTG Over $1,000 PAR was granted in part (checked October 20, 2026).

Medical Treatment: this form is to be used when a medical request has been denied and you are requesting assistance from the Board regarding one of the reasons listed in box h.

If prior authorization has not been requested yet and is required, your health care provider must submit a Prior Authorization Request (PAR).

Box i: My Medication, Durable Medical Equipment, MTG Variance or MTG Special Services PAR was denied or granted in part by the Medical Director's Office. Attach "Notice of Resolution" regarding treatment.

Box j: My disability is now permanent. Attach Doctor's Report of MMI/Permanent Impairment (Form C-4.3). Check this box if you were under 25 years of age at time of accident.

Box k: My medical condition has changed. Attach medical forms.

Box l: My request for medical and transportation reimbursement was denied or has not been addressed. Attach receipts and Form C-257.

Box m: I have new information and/or information requested by the Board regarding (Attach documents):

Box n: Other (Explain in the space provided in Other Issues):

**Document reference information (date, name/title, form ID): for the Reason for this Request, if the additional information was already submitted, do not attach it, but identify it here by giving the form number or title and the date it was submitted to the Board.

Sign on the Injured Worker Signature line and enter the Date.

Complete the identifying information at the top of Form RFA-1W and send the form, with all applicable information attached, to: Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205. Address for Email Filing: wcbclaimsfiling@wcb.ny.gov. The Board will contact you and all parties when it takes action on your claim. *After each check box you will see the information needed in bold letters.

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.

Any person who knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self insurer, any information containing any false material statement or conceals any material fact shall be guilty of a crime and subject to substantial fines and imprisonment.