Employee Claim C-3

State of New York - Workers' Compensation Board

Fill o u t t h i s f o r m t o a p p l y f o r w o r k e r s ' c o m p e n s a t i o n b e n e f i t s b e c a u s e o f a w o r k i n j u r y o r w o r k - r e l a t e d i l l n e s s . T y p e o r
print neatly. T h i s f o r m m a y a l s o b e filled o u t on-line a t w w w . w c b . s t a t e . n v . u s .

W C B C a s e N u m b e r ( i f y o u k n o w it): G1868478 0000545937

A . YOUR INFORMATION (Employee)

1. N a m e : Daniel Uber 2 . D a t e o f Birth: 07/24/1954
Last

3 . MailingAddress: 3 2 Crescent city, Mobile Home Park Clifton Park NY 12065

N u m b e r a n d Street/PO B o x City State Zip Code

4 . Social Security Number: XXX-XX-0573 5. Phone Number: {518)280-7611 6. Gender: [X] Male [ ] Female

7. Will y o u need a translator if y o u have to attend a Board hearing? [ ] Yes [ ] No If yes, for what language? English

B. YOUREMPLOYER(S)
1. E m p l o y e r w h e n i n j u r e d : Shenendehowa School 2 . Phone N u m b e r

3. Your w o r k address; 5 Chelsea Place Clifton Park NY 12065

N u m b e ra n d Street City ZipCode

4 . Date y o u w e r e hired: 5. Your supervisor's name:

6. List names/addresses of any other employer(s) at the time of your injury/illness:

7. Did y o u lose time from work at the other employment(s) as a result o f your injury/illness? [ ] Y e s [ ] No

C. YOUR J O B o n the date of the injury o r illness

1. What w a s your j o b title or description? B u s Monitor

2. W h a t types o f activities did you normally perform at work?

3. W a s your j o b ? (check one) [ ] Full T i m e [X] Part Time [ ] Seasonal [ ] Volunteer [ ] Other:

4. W h a t w a s your gross pay (before taxes) per pay period? 942.00 5. How often were y o u paid? Bl-Weekly

6. Did y o u receive lodging or tips in addition t o your pay? [ ] Y e s [ ] No If yes, describe:

D. YOUR INJURY OR ILLNESS

1. Date of injury or date o f onset o f illness: 07/17/2017 2 . Time of injury:

3. W h e r e did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)

Route 146, Altamont, NY 12009

4. W a s this your usual work location? [ ] Y e s [ X ] No If no, why were y o u at this location?

M y j o b requires travel.

5. W h a t were you doing w h e n y o u were injured or became ill? (e.g., unloading a truck, typing a report)

I w a s sitting In the school bus monitoring kids with special needs.

6. H o w did the injury/illness happen (e.g., I tripped over a pipe and fell on the floor) I w a s kicked In the eye by o n e of the kids.

7. Explain fully the nature of your injury/illness: list body parts affected (e.g., twisted left ankle a n d cut to forehead): Left eye

T H E WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE

C -3. 0(1-1 1 ) P a g e l o f 2 WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.state.ny.us
 YOUR NAME: Daniel Uber DATE O F INJURY/ILLNESS: 07/17/2017

D. YOUR INJURY OR ILLNESS continued

8. W a s an object (e.g., forklift, hammer, acid) involved in the injury/illness? [ ] Y e s [ X ] No If yes, what?

9. W a s the injury the result of the use or operation of a licensed motor vehicle? [ ] Y e s [X] No

If yes, [ ] your vehicle [ ] employer's vehicle [ ] other vehicle License plate number (if known):

If your vehicle w a s involved, give n a m e and address of your motor vehicle insurance carrier:

10. Have y o u given your employer (or supervisor) notice o f injury/illness? [X] Y e s [ ] No

If yes, notice Vi'as given to: [X] orally[ ] in writing Date notice given: 07/17/2017

11. Did anyone s e e your injury happen? [ ] Y e s [ ] No [ ] Unknown If yes, list names:

E. RETURN TO WORK
1. Did y o u stop work because of your injury/illness? [X] Yes, o n w h a t date? 07/17/2017 [ ] No, skip t o Section F.

2. Have y o u returned to work? [ ] Y e s [X] N o If yes, o n w h a t date? [ ] regular duty [ ] limited duty

3. If you have returned to work, w h o are y o u working for nov/? [ ] S a m e employer [ ] New Employer [ ] Self employed

4. What is your gross pay (before taxes) per pay period? How often are y o u paid?

F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS

1. What w a s the date o f your first treatment? 07/17/2017 [ ] None received (skip t o question F-5)

2. W e r e y o u treated o n site? [ ] Y e s [ X ] No

3. Where did y o u receive your first off site medical treatment for your injury/illness? ( ] none received [ ] Emergency Room

[ ] Doctor's office [ ] Clinic/Hospital/Urgent Care [ ] Hospital Stay over 2 4 hours

Name a n d address where y o u were first treated:

Phone Number:

4. Are y o u still being treated for this injury/illness? [X] Y e s [ ] No

Give the name a n d address o f the doctor(s) treating y o u for this injury/illness: Albany Medical Center

4 3 N e w Scotland Avenue, Albany, N Y 12208 Phone Number: (518) 262-3125

5. Do y o u remember having another injury t o the same body part o r a similar illness? ( ] Yes [X] No

If yes, were y o u treated by a doctor? [ ] Yes [ ] N o If yes, provide the names a n d addresses of the doctor(s) w h o treated
y o u and C O M P L E T E A N D FILE F O R M C-3.3 T O G E T H E R W I T H THIS FORM:

6. W a s the previous injury/illness v/ork related? [ ] Yes [ ] No

If yes, were y o u working for the s a m e employer that y o u w o r k for now? ( ] Yes [ ] No

I a m h e r e b y m a k i n g a c l a i m f o r b e n e f i t s u n d e r t h e Worlcers' C o m p e n s a t i o n L a w . M y s i g n a t u r e a f f i r m s t h a t t h e i n f o r m a t i o n i a m p r o v i d i n g is t r u e
a n d accurate t o t h e best o f m y icnowiedge a n d beiief.

A i y p e r s o n w h o k n o w i n g l y a n d w i t h i N T E N T T O D E F R A U D p r e s e n t s , c a u s e s t o b e p r e s e n t e d , o r p r e p a r e s w i t h k n o w l e d g e o r b e i i e f t h a t it
w i l l b e p r e s e n t e d t o , o r b y a n i n s u r e r , o r s e l f - i n s u r e r , a n y i n f o r m a t i o n c o n t a i n i n g a n y F A L S E MATERIAL STATEMENT o r c o n c e a l s a n y
m a t e r i a l fact, S H A L L B E G U I L T Y O F A C R I M E a n d s u b j e c t t o s u b s t a n t i a l F I N E S A N D I M P R I S O N M E N T .

Employee's Signature: GiMMtL Print Name: 7/27/^017/

O n behalf o f Errployee: Print Name: Date: / /

A n individual m a y s i g n o n b e h a l f o f t h e e m p l o y e e o n l y if h e o r s h e is legally a u t h o r i z e d t o d o s o a n d t h e e m p l o y e e is a m i n o r , mentally i n c o m p e t e n t o r incapacitate d.

I certify t o t h e b e s t o f m y k n o w l e d g e , in fo rma tio n a n d belief, f o r m e d a fte r a n inquiry r e a s o n a b l e u n d e r t h e c i r c u m s t a n c e s , t h a t t h e allegations a n d o t h e r f a c t u a l m a t t e r s a s s e r t e d

a b o v e h a v e e v i d e n t i a r y s u p p o r t , o r a r e likely t o h a v e e v i d e n t i a r y s u p p o r t after a r e a s o n a b l e o p p o r t u n i t y f o r f u r t j j e r investigations o r d i s c o v e r y .

Signature o f Attorney/Representative (if any):

Print Name: Andrew Finkelstein Title: Attorney

ID No., if any: ^ 233008 If Licensed Representative, License No. Expiration Date:

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