New York Workers' Compensation Direct Deposit

To begin, change, or cancel the deposit of workers’ compensation benefit checks and/or proceeds from a settlement agreement under Section 32 of the Workers’ Compensation Law (hereinafter “settlement proceeds”) directly to a financial institution, complete the enclosed form and mail to: 

Greater New York Mutual Insurance Company

Workers’ Compensation Department

200 Madison Avenue, Third Floor

New York, New York 10016

An additional copy of the form is available at www.GNY.com.  Do not send the form to the Workers’ Compensation Board.

YOUR OPTIONS CONCERNING DIRECT DEPOSIT

You may receive your workers' compensation indemnity benefits or death benefits by direct deposit or by paper check in the mail.

You may cancel direct deposit at any time by checking the appropriate box on the enclosed form, completing the remainder of the form, and forwarding the completed form to the address shown above.  Your request to cancel direct deposit will be implemented within forty-five days of our receipt of a completed form, and thereafter payment of benefits will be sent to you by paper check to the mailing address indicated on the form.

You may have your indemnity or death benefits directly deposited into up to two bank accounts either as a percentage of the total benefit or a fixed dollar amount for each deposit.  We require a minimum amount of $20 to be deposited into each bank account.

YOUR AUTHORIZATIONS, UNDERSTANDINGS, AND ACKNOWLEDGEMENTS

By electing direct deposit payments for your indemnity or death benefits, you agree to be bound by all terms of the process, which includes specific terms and limitations that we and the New York State Workers’ Compensation Board may set for this process.

Your initial direct deposit payment will be for a $1.00 test payment, which will be deducted from your indemnity or death benefits due.  Upon receiving your confirmation that you received the initial direct deposit of $1.00, we will update your account information to have your future indemnity or death benefits paid by direct deposit.  Should you elect to deposit into two accounts, an initial direct deposit test payment of $1.00 will be required for each account. Please be advised that it could take up to 45 days to complete the direct deposit process.  You will continue receiving payments by regular mail until the process is completed.

By electing direct deposit payments for your indemnity or death benefits, you expressly: 

•  Authorize us to directly deposit your workers' compensation indemnity benefits or death benefits into the bank account(s) identified on the enclosed form. 
•  Authorize us to debit your account or otherwise lawfully proceed to recover any credit(s) deposited in error.  IMPORTANT: This consent does not authorize GNY to recover alleged over payments of established and awarded benefits.
•  Understand and acknowledge that any change in your employment status may affect your right to receive benefits.
•  Understand and acknowledge that any false statement or failure to disclose a material fact in order to obtain or increase your benefits may result in criminal prosecution, disqualification from benefits, and repayment of any funds deposited to your account.
•  Understand and acknowledge that the failure to notify us of any change in financial institution or account may delay receipt of your benefits or settlement proceeds.
•  Understand and acknowledge that you must submit a new completed form to us to change or cancel the direct deposit of your workers’ compensation indemnity or death benefits.
•  Understand and acknowledge that you have an obligation to immediately notify us should you no longer be entitled to payments, or of any change in circumstances that may affect your entitlement to payment.
• Understand and acknowledge that we may require you to certify annually that you continue to elect the receipt of indemnity or death benefits by direct deposit, and that we may discontinue direct deposit and thereafter provide benefits by paper check should you fail to timely provide us with the requested certification.

By submitting to us the enclosed form and accepting workers’ compensation indemnity or death benefits by direct deposit, the payee, under penalty of fine and/or imprisonment, certifies entitlement to the payment for benefits or services, circumstances affecting such entitlement have not changed, and no false statements or representations have been made in support of the claim for payment. False representations could result in civil and criminal penalties. Your failure to notify us within 14 days of a change in your eligibility status for continuing indemnity payments may result in the legal procedures provided in sections 300.23(a)(2) or 300.23(b)(3) of the NYCRR.