NY HIMP-1 2009 free printable template

New York State Workers' Compensation Board Health Insurers' Match Program Part I Health Insurer's/Health Benefit Plan's Request for Reimbursement WEB Case Number Claimant's Social Security No. Date

Company Employee's Signature to All Forms for Workers' Compensation Insurance Company (Copy of Social Security Card) Copy of Insurer's Claim ID No. (The earliest date the claim is no longer under dispute.) (If previously filed for this case) Name and Address of Social Security Account holder Employer's Signature to form for Social Security Employer (Copy of Social Security Card) (If earlier than claimed) Name and Address of Claimants Signature to all other forms for Workers' Compensation Insurance Company (Copy of Social Security Card) (If earlier than claimed) (If previously filed for this case) Name and Address of All Claimants (or an authorized representative). If you have more than one insured worker on your insurance policy, the first step in the approval process of your insurance company's “Reimbursement Request” is to give the appropriate insurance carrier a copy of your claim ID number. It has been suggested that your company keep the “Claim ID No.” on file with your insurance agency. The insurance carrier can then use the “Claim ID Number” to check your claim history against yours to determine if you are eligible for a reimbursement. However, your insurance company is under no obligation to reimburse you. Once the insurance coverage is approved, the insurer files your first “Reimbursement Request” with the Health Insurance Claim (HIC) Bureau (see instructions below for obtaining a copy of the HIC Registry), which is a regional office of the New York State Workers' Compensation Board. Because your company is responsible for your claim, it must take full responsibility for paying the reimbursement. Once you receive a “Reimbursement Request” from Health Insurance Claim (HIC), contact the HIC Bureau at your insurance company's location at the address in the “Address to Write to” box on the last page of the “Reimbursement Request” to request a “Reimbursement Receipt.” This record must be maintained with your worker's compensation insurance policy for one year after the claim is paid. You must also report to your insurance company any payment changes that you made to ensure that your company will be reimbursed for those payments. The HIC Bureau cannot issue reimbursement receipt until it has received and verified each claim and received all necessary information from you concerning the claim.

For pdfFiller’s FAQs

What is himp-1109 - workers39 compensation?

HIMP-1109 is a form used to report workers' compensation information.

Who is required to file himp-1109 - workers39 compensation?

Employers are typically required to file HIMP-1109 for workers' compensation purposes.

How to fill out himp-1109 - workers39 compensation?

HIMP-1109 can be filled out by providing the requested information such as employee details, injury description, and compensation details.

What is the purpose of himp-1109 - workers39 compensation?

The purpose of HIMP-1109 is to collect and report information related to workers' compensation cases.

What information must be reported on himp-1109 - workers39 compensation?

Information such as employee details, injury description, compensation amounts, and other relevant data must be reported on HIMP-1109.

When is the deadline to file himp-1109 - workers39 compensation in 2023?

The deadline to file HIMP-1109 for workers' compensation in 2023 is usually determined by the relevant authorities or regulatory bodies.

What is the penalty for the late filing of himp-1109 - workers39 compensation?

The penalty for the late filing of HIMP-1109 for workers' compensation may vary depending on the jurisdiction and applicable regulations.

Can I sign the himp-1109 - workers39 compensation electronically in Chrome?

Yes. You can use pdfFiller to sign documents and use all of the features of the PDF editor in one place if you add this solution to Chrome. In order to use the extension, you can draw or write an electronic signature. You can also upload a picture of your handwritten signature. There is no need to worry about how long it takes to sign your himp-1109 - workers39 compensation.

Can I create an eSignature for the himp-1109 - workers39 compensation in Gmail?

You can easily create your eSignature with pdfFiller and then eSign your himp-1109 - workers39 compensation directly from your inbox with the help of pdfFiller’s add-on for Gmail. Please note that you must register for an account in order to save your signatures and signed documents.

How do I edit himp-1109 - workers39 compensation on an Android device?

You can make any changes to PDF files, like himp-1109 - workers39 compensation, with the help of the pdfFiller Android app. Edit, sign, and send documents right from your phone or tablet. You can use the app to make document management easier wherever you are.