Form I-15 "Workers' Compensation Authorization" - New York

What Is Form I-15?

This is a legal form that was released by the New York State Office of Victim Services - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the New York State Office of Victim Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form I-15 by clicking the link below or browse more documents and templates provided by the New York State Office of Victim Services.

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Download Form I-15 "Workers' Compensation Authorization" - New York

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ANDREW M. CUOMO
ELIZABETH CRONIN ESQ.
Governor
Director
WORKERS’ COMPENSATION AUTHORIZATION
I hereby authorize the New York State Workers’ Compensation Board to provide the
New York State Office of Victim Services, or its representatives, any and all information
with respect to any claim made relating to an incident for which a claim has been made to
the Office of Victim Services.
______________________________
____________________
(SIGNATURE OF CLAIMANT)
(DATE)
State of New York
County of ____________________
On this _______________ day of ________________20_______, before me, the
undersigned Notary Public in and for the State of ________________________________
personally appeared _________________________________, personally known to me or proved to
me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within
instrument and acknowledged to me that (s)he executed the same in his/her capacity and by his/her
signature on the instrument (s)he executed the instrument.
___________________________________
______________________
Notary Public
Seal/Stamp
*I-15*
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210 │ 800-247-8035 │www.ovs.ny.gov
ANDREW M. CUOMO
ELIZABETH CRONIN ESQ.
Governor
Director
WORKERS’ COMPENSATION AUTHORIZATION
I hereby authorize the New York State Workers’ Compensation Board to provide the
New York State Office of Victim Services, or its representatives, any and all information
with respect to any claim made relating to an incident for which a claim has been made to
the Office of Victim Services.
______________________________
____________________
(SIGNATURE OF CLAIMANT)
(DATE)
State of New York
County of ____________________
On this _______________ day of ________________20_______, before me, the
undersigned Notary Public in and for the State of ________________________________
personally appeared _________________________________, personally known to me or proved to
me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within
instrument and acknowledged to me that (s)he executed the same in his/her capacity and by his/her
signature on the instrument (s)he executed the instrument.
___________________________________
______________________
Notary Public
Seal/Stamp
*I-15*
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210 │ 800-247-8035 │www.ovs.ny.gov