Wtc 12 Form – Fill Out and Use This PDF

State of New York

WORKERS' COMPENSATION BOARD

REGISTRATION OF PARTICIPATION IN WORLD TRADE CENTER RESCUE,

RECOVERY AND/OR CLEAN-UP OPERATIONS

(Sworn Statement Pursuant to Workers' Compensation Law §162)

Please read the background and instructions below completely and carefully before completing the Sworn Statement

beginning on page 3.

BACKGROUND

1.On August 14, 2006, Workers' Compensation Law (WCL) Article 8-A was enacted to expand the time for a "participant" in World Trade Center rescue, recovery and/or clean-up operations who suffers, or may suffer in the

future, from a "qualifying condition" to file	a claim for	workers' compensation lost wage	and medical benefits and
to permit the Board to reopen such claims	previously	denied as untimely. Article 8-A	was recently amended

to change the definition of “qualifying condition” and to extend the registration deadline.

2.A "Participant in World Trade Center rescue, recovery, or cleanup operations" (referred to as "participant") is defined in WCL §161(1) as any:

(a)employee who within the course of employment, or (b) volunteer upon presentation to the Board of evidence satisfactory to the Board that he or she:

(i)participated in the rescue, recovery, or cleanup operations at the World Trade Center site between September 11, 2001 and September 12, 2002, or

(ii)worked at the Fresh Kills Land Fill in New York City between September 11, 2001 and September 12, 2002, or (iii) worked at the New York City morgue or the temporary morgue on pier locations on the west side

of Manhattan between September 11, 2001 and September 12, 2002, or

(iv)worked on the barges between the west side of Manhattan and the Fresh Kills Land Fill in New York City between September 11, 2001 and September 12, 2002.

3."World Trade Center site" is defined as "anywhere below a line starting from the Hudson River and Canal Street; east on Canal Street to Pike Street; south on Pike Street to the East River; and extending to the lower tip of Manhattan."

4.A "qualifying condition" is defined as "any of the following diseases or condition resulting from a hazardous exposure during participation in World Trade Center rescue, recovery or clean-up operations:

(a)Diseases of the upper respiratory tract and mucosae, including conditions such as conjunctivitis, rhinitis, sinusitis, pharyngitis, laryngitis, vocal cord disease, upper airway hyper-reactivity and trachea- bronchitis, or a combination of such conditions;

(b)Diseases of the lower respiratory tract, including but not limited to bronchitis, asthma, reactive airway dysfunction syndrome, and different types of pneumonitis, such as hypersensitivity, granulomatous, or eosinophilic;

(c)Diseases of the gastroesophageal tract, including esophagitis and reflux disease, either acute or chronic, caused by exposure or aggravated by exposure;

(d)Diseases of the psychological axis, including post-traumatic stress disorder, anxiety, depression, or any combination of such conditions; or

(e)New onset diseases resulting from exposure as such diseases occur in the future including cancer, chronic obstructive pulmonary disease, asbestos-related disease, heavy metal poisoning, musculoskeletal disease and chronic psychological disease.

5.In order for the claim of a participant in World Trade Center rescue, recovery or cleanup operations to come within the application of Article 8-A of the Workers' Compensation Law, the participant is required to register

with the Workers' Compensation Board ("Board"). The registration form (WTC-12) must be filed not later than September 11, 2022.

6.To register, this Sworn Statement must be accurately and truthfully completed and the original filed with the Board District Office or Downstate Central Mailing Center (see addresses below) not later than September 11, 2022.

INSTRUCTIONS

A.If you were a "participant" in World Trade Center rescue, recovery, and/or cleanup operations, as that term is defined above, you are required to provide information requested by the Board in the accompanying Sworn Statement if you were exposed to hazardous conditions which cause you to suffer, or may cause you to suffer in the future, from a "qualifying condition" for which you will or may file or have filed a claim for workers' compensation benefits.

WTC-12 (9-18)

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NYS Workers’ Compensation Board Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902

www.wcb.ny.gov

B.Please complete the Sworn Statement by providing the following information:

Item 1 - Give your current residential address, including apartment number (if applicable), street number, street name,

city, state and zip code. Give mailing address		if different from the residential address provided.		Be sure to include
your telephone number. Please provide your Social Security			Number and your date of birth by month/date/year.
Item 2 - This sentence just states that	you	participated in	the World Trade Center rescue, recovery and cleanup
operations between September 11, 2001,	and	September 12, 2002, at the World Trade Center		site, the Fresh Kills

Land Fill, the New York City morgue or temporary morgue, or the barges between the west side of Manhattan and

the Fresh Kills Land Fill.
Item 3 -	State	whether you participated in the		World Trade Center rescue, recovery				and/or clean-up operations
as an employee		(in the course of your employment for pay) or as a volunteer (not in the course of your employment,
but upon your own initiative without pay);
Item 4 -	List with a brief		description any evidence of your		activities as	a volunteer,		for	example, badge, letters,
statements, pictures, accommodations, etc.;
Item 5 -	Fill in the table. Specify the dates and locations of your participation in World Trade Center rescue,
recovery and/or cleanup operations to the best of your ability.					Describe the work you performed at each						location on
the date or dates you were there. Give the complete name					and address of your employer (s) or the rescue
entity/volunteer agency you volunteered with during the period of participation in World Trade Center											rescue,
recovery	and/or clean-up operations, and if applicable and				you know,	the name of your employer's insurance
carrier; and
Item 6 - Indicate whether			you previously filed	a workers'	compensation	claim	with	the	Board	relating to your
participation in		World Trade Center rescue, recovery and/or cleanup operations.					If	you	have,	you must include
the date the claim was filed and the WCB case number.
Item 7 - This item states your understanding that filing					the Sworn Statement, and thereby registering as a
"participant," is not the same as filing a claim for workers' compensation						benefits. To		file a claim for benefits you
must timely submit to the Board Form C-3 or Form WTCVol-3.
Item 8 -	This	item states	that you understand	that the law	penalizes those who		submit		false written documents

to the Board and for making false statements.

C.After you complete the Sworn Statement, please review it to insure that it is truthful and accurate.

D.Sign the Sworn Statement in front of a notary public. Your signature on the Sworn Statement must be notarized or the comparable process for the jurisdiction in which you are located when signing this Statement. Do not sign the Sworn Statement until you are in the presence of the notary public. PLEASE NOTE: by signing this statement, you swear and affirm that the information provided and statements made therein are true under the penalty of perjury. You are also stating that you understand that the law prescribes penalties for perjury, for willfully making false statements in connection with an insurance claim, and for submitting a false instrument for filing.

E.You must file the original Sworn Statement with the Board not later than September 11, 2022 to the Board’s Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902.

ADDITIONAL INFORMATION

F.Filing this Sworn Statement with the Board is NOT considered the filing of a claim for workers' compensation benefits. In order to file a claim for workers' compensation benefits, you must submit a Form C-3 (Employee's Claim for Compensation) or WTCVol-3 (World Trade Center Volunteer's Claim for Compensation) to the Board in a timely manner.

G.PLEASE NOTE: If you previously filed a claim for workers' compensation benefits relating to your participation in World Trade Center rescue, recovery and/or cleanup operations, which was disallowed by the Board because you did not give timely notice to your employer or did not file a claim with the Board within the time allowed, the Board

will reopen and reconsider such claim PROVIDED your Sworn Statement is filed with the Board not later than September 11, 2022.

H.PLEASE NOTE:

§"participant" must register by filing a Sworn Statement with the Board not later than September 11, 2022, in order for the extended claim filing period to apply to his/her claim.

§If a "participant" has already filed a claim for workers' compensation benefits for a "qualifying condition" which was disallowed as untimely and now fails to timely file a Sworn Statement with the Board, the "participant's" claim will not

be reopened and reconsidered by the Board. Except that a claim by a participant in the World Trade Center rescue, recovery or cleanup operations whose disablement occurred between September 11, 2012 and September 11, 2017,

shall not be disallowed as barred by Section 18 or Section 28 of this chapter if such claim is filed on or before September 11, 2022. Any such claim by a participant in the World Trade Center rescue, recovery or cleanup operations whose disablement occurred between September 11, 2012 and September 11, 2017, and was disallowed by Section 18 or 28 of this chapter shall be reconsidered by the Board.

§The extended period in which to file a claim will only apply to the claim of a "participant" who registers by filing a Sworn Statement with the Board not later than September 11, 2022.

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NYS Workers’ Compensation Board Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902

www.wcb.ny.gov

Registration of Participation in World Trade Center

Rescue, Recovery and/or Clean-up Operations

(Sworn Statement Pursuant to Workers' Compensation Law §162)

REGISTRATION IS NOT THE FILING OF A CLAIM FOR WORKERS' COMPENSATION BENEFITS

In the Matter of the Registration of

_______________________________, Participant

(Your first name, middle initial and last name)	SWORN STATEMENT
Regarding Participation in World Trade Center	WCL§162

Rescue, Recovery and/or Clean-up Operations.

*******************************

State of_________________________________________________________ )

(State/province where you have thisnotarized)

) ss

County of ______________________________________________

(County, or country ifoutside U.S.A., where you have this notarized)

I,		(print first name, middle initial and last name) being duly
sworn, depose and say:

1.I am the above named Participant, and I reside at ________________________________________________

___________________________________________________ (provide street number and name, city, state, zip code and country if not U.S.A.). My mailing address (if different from residential address is

________________________________________________________________________________________. My telephone number is ____________________ (area code, number). My Social Security Number is

_________________ (optional) and my date of birth is _______________________.

2.I was a participant in World Trade Center rescue, recovery, and/or clean-up operations as that term is defined in Workers' Compensation Law §161 (1). (See instruction page for complete definition.)

3.I participated in the World Trade Center rescue, recovery and/or clean-up operations as defined in Workers' Compensation Law §161 (1) as (specify whether participated as an employee or volunteer)

_____________________. (A	person participated as an employee if he/she was in the course of his/her employment and
was paid. A person participated as	a volunteer if it was not part of his/her employment he/she was not directed to participate

by the employer and he/she was not paid for the services performed.)

4.I have the following evidence of my activities as a volunteer __________________________________

________________________________________________________________________________________ (list

any evidence such as pictures, badges, letters, etc. of your volunteer activities). (If you did not participate as a volunteer, cross

out this paragraph.)

5.The date(s) and location(s) where I worked as a participant, a description of the work I performed, the

name and address of my employer while a participant or the name of the agency or entity that directed my volunteer participation, and the insurance carrier, if applicable and/or known for my employer are as follows:

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NYS Workers’ Compensation Board Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902

www.wcb.ny.gov

6.I (state whether you have or have not) ___________________________ filed a claim with the Workers' Compensation Board (hereinafter referred to as "Board") relating to my participation in World Trade Center rescue, recovery and/or clean-up operations as defined in Workers' Compensation Law §162 (1). I filed my claim on _____________________ (date claim was filed with the

Workers' Compensation Board) and the "WCB Case No." for the claim filed is _______________ (eight digit

number assigned by the Workers' Compensation Board).

7.I understand that by filing this Sworn Statement with the Board I am not filing a claim for benefits and the Board will not create a case file. I understand that to file a claim Imust timely submit to the

Board Form C-3, Employee's Claim for Compensation, or Form WTCVol-3, World Trade Center Volunteer's Claim for Compensation.

8.I understand that the law prescribes penalties for perjury, for knowingly making false statements in a written instrument offered for filing with a public entity such as the Board, and for willfully making false statements in connection with an insurance claim. By signing my name below I swear and affirm under penalty of perjury that the information and statements I have made herein are true.

______________________________________

CompleteSignature

(ink only -- use blue ballpoint pen if possible)

Sworn to before me this ________________ day

of _____________________________, 20_____

________________________________________

Notary Public

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NYS Workers’ Compensation Board Centralized Mailing Address: P.O. Box 5205, Binghamton, N.Y. 13902

www.wcb.ny.gov