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Form

Description

C2F.pdf Employer's Report of Work-Related Injury/Illness
c2Finst.pdf Employer's First Report of Work-Related Injury/Illness - Instructions
a9.pdf Notice that You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim is Disallowed, or if Agreement Pursuant to WCL 32 is Approved (English/Spanish)
adr1.pdf Alternative Dispute Resolution Program Report of Injury (Print form on WHITE paper, not green)
adr1_1.pdf Alternative Dispute Resolution Program Modification of Previous Report
adr2.pdf Alternative Dispute Resolution Program Final Disposition or Settlement of Claim (Print form on WHITE paper, not green)
aff1.pdf Affidavit for Death Benefits
bp-1.pdf Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
bp1.pdf BP-1 Cover Letter
c3Poster.pdf Poster - C-3 Poster
c3inst.pdf Instructions for Completing Form C-3
c3.pdf Employee Claim
c3S.pdf Employee Claim (Spanish)
InjuredOnTheJob.pdf BROCHURE - Injured on the Job, an Employee's Guide to Workers' Compensation in New York State
CIP.pdf Claimant Information Packet
CIP_Sp.pdf Claimant Information Packet (Spanish)
c3_1.pdf Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider (English/Spanish)
c3_3.pdf Limited Release of Health Information (HIPAA)
c3_3s.pdf Limited Release of Health Information(HIPAA)(Spanish)
c4.pdf Doctor's Initial Report
ce200apply.pdf Application for Certificate of Attestation of Exemption
c4_1.pdf Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4
c4_2.pdf Doctor's Progress Report
c4_3.pdf Doctor's Report of MMI/Permanent Impairment
C-4AMR.pdf Ancillary Medical Report
c4AUTH.pdf Attending Doctor's Request for Authorization and Carrier's Response
c5.pdf Attending Ophthalmologist's Report
c8_1.pdf Notice of Treatment Issue/Disputed Bill
c8_4.pdf Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s)
c11.pdf Employer's Report of Injured Employee's Change in Status or Return to Work
c21.pdf Application for Advance on Periodic Payments of Compensation
c22.pdf Application for Approval of Non-Schedule Adjustment (Print form on 14 inch paper)
c25.pdf Application for Reopening of Claim, More Than Seven Years After Accident
c27.pdf Medical Proof of Change in Condition in Support of Application for Reopening
c32.pdf Waiver Agreement, Section 32
c32sp.pdf Waiver Agreement, Section 32 (Spanish)
c32_I.pdf Settlement Agreement-Section 32, Indemnity Only Settlement Agreement
c32_I-sp.pdf Settlement Agreement-Section 32, Indemnity Only Settlement Agreement (Spanish)
c32_1.pdf Section 32 Settlement Agreement: Claimant Release
c32_1sp.pdf Section 32 Settlement Agreement: Claimant Release (Spanish)
c62.pdf Claim for Compensation in Death Case
c62_s.pdf Claim for Compensation in Death Case (Spanish)
c64.pdf Proof of Death by Physician Last in Attendance on Deceased
c65.pdf Proof of Burial and Funeral Expenses by Undertaker
c72_1.pdf Record of Percentage Hearing Loss
c105_11.pdf Consent to NYS Workers' Compensation Board Jurisdiction for Non-New York Licensed Carriers (3C Coverage)
c105_31.pdf Notice of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers under Coverage of WCL
c105_32.pdf Notice of Election of a Partnership, Limited Liability Partnership, Professional Limited Liability Partnership, Limited Liability Company, Professional Limited Liability Company or Sole Proprietorship to Bring Partners, Members or Self-Employed Persons U
c105_41.pdf Revocation of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL
c105_51.pdf Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage
c105_52.pdf Notice of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage
c105_53.pdf Revocation of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage
c105_54.pdf Notice of Election to Bring Sheltered Workshop Participants under Coverage of WCL
c105_55.pdf Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage
c121.pdf Claim for Compensation and Notice of Commencement of Third Party Action
c240.pdf Employer's Statement of Wage Earnings Preceding Date of Accident
c251.pdf Carrier's Request for Reimbursement of Compensation Payments Under Section 15-8
c251a.xlsx Carrier's Request for Reimbursement of Indemnity Payments Under WCL 15(8)
c251n.xlsx Carrier's Request for Initial Reimbursement of Indemnity Payments Under WCL 15(8)
c251_1.pdf Carrier's Request for Reimbursement of Medical Expenses under Section 15-8
c251_2.pdf Carrier's Request for Reimbursement of Compensation Payments under Section 14(6) Concurrent Employment
c251_2A.xlsx Carrier's Request for Reimbursement of Indemnity Payments Under WCL 14(6)
c257.pdf Claimant's Record of Medical and Travel Expenses
c258.pdf Claimant's Record of Job Search Efforts/Contacts
c300_34.pdf Statement of Unresolved Issues (Special Part for Expedited Hearings)
c300_5.pdf Stipulation
c312_5.pdf Agreed Upon Findings and Awards for Proposed Conciliation Decision Represented Claimants Only
c430s.pdf Statement of Rights (WCL)
cb11.pdf Conciliation Process (Rights and Responsibilities)
cb11s.pdf Conciliation Process (Rights and Responsibilities) (Spanish)
db102.pdf Information for Employer Regarding Disability Benefits Law
db118.pdf Employer's Statement for the Purpose of Terminating Status as a Covered Employer
db125.pdf Employer Identification Card
db130.pdf Employee's Statement of Exempt Status
db135.pdf Employer's Application for Voluntary Coverage for Class of Employees for Whom Disability Benefits are not Required by Law (No Employee Contribution)
db136.pdf Employer's Application for Voluntary Coverage for Class of Employees for Whom Disability Benefits are not Required by Law (Employee Contribution)
db159_1.pdf Notice of Termination of Employer's Participation in Self-Insured Association, Union or Trustees Plan
db212_3.pdf Notice of Election of a Corporation which is Required to have Disability Benefits Coverage for its Employees to Exclude the Sole Shareholder Officer or One of the Two or Both Shareholder Officers of the Corporation from such Coverage
db212_5.pdf Notice of Election of Voluntarily Exclude Spouse from Coverage
db271s.pdf Statement of Rights (DBL)
db300.pdf Notice of Proof of Claim for Disability Benefits of Unemployed Claimant
db450.pdf Notice and Proof of Claim for Disability Benefits
DB-450_Spanish.pdf Notice and Proof of Claim for Disability Benefits (Spanish)
db455.pdf Notice of Disability Benefits Payment
db470.pdf DB-470 Preliminary/Final Claim for Reimbursement of Benefits Paid under DBL - Not available online. Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form.
db791.pdf Tables of Permanent Contributions
db802.pdf Employer's Application to have Association, Union or Trustee Plan Accepted as Employer's Plan
db820_1.pdf Supplement to Certificate of Insurance
db840.pdf Carrier's Designation of Authorized Representatives
db850.pdf Application for Acceptance of Insurance Form
dc120.pdf Discharge or Discrimination Complaint
DD-1.pdf Direct Deposit and Debit Card Authorization Form
DD-2.pdf Biannual Recertification to Entitlement to Benefits
dt1.pdf Notice that Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider
electronicattach.pdf Attachment to Form_____ (may accompany any Board form)
fce-4.pdf Practitioner's Report of Functional Capacity Evaluation
himp_1.pdf Health Insurer's Request for Reimbursement
HIPAA-1.pdf Claimant's Authorization to Disclose Health Information (Pursuant to HIPAA)
hp1.pdf Health Provider's Request for Decision on Unpaid Medical Bill(s)
hp4.pdf Notice to Chair: Health - Provider's and Insurer's Withdrawal of Request for Arbitration
HPJ1.pdf Provider's Request for Judgment of Award (WCL 54-b)
IG1.pdf Workers' Compensation Fraud Inspector General Complaint Form
IG2.pdf Employer Fraud Referral Form
ime3.pdf Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination
ime4.pdf Independent Examiner's Report of Independent Medical Examination
ime5.pdf Claimant's Notice of Independent Medical Examination
ime7.pdf Statement of Registration (Sec. 13n -WCL)
IS1.pdf Physician's Application for Designation as an Impartial Specialist
IS1R.pdf Physician's Application for Renewal of Designation as an Impartial Specialist
IS4.pdf Physician's Report of Impartial Specialist Examination or Impartial Specialist Record Review
lac1.pdf Language Access Comment Form
lac1s.pdf Language Access Comment Form (Spanish)
md-1.pdf Attending Doctor's Request for Medical Authorization Determination
md-3.pdf Carrier/Board-approved self-insured employer's Objection to Attending Doctor's Request for Medical Authorization Determination
MG1.pdf Attending Doctor's Request for Optional Prior Approval and Carrier's / Employer's Response
MG1_1.pdf Continuation to Form MG-1, Attending Doctor's Request for Optional Prior Approval
MG2.pdf Attending Doctor's Request for Approval of Variance and Carriers's Response
MG2_1.pdf Continuation to form MG-2, Attending Doctor's Request for Approval of Variance
MR4.pdf Impartial Specialist's Report of Medical Records Review
mr-ime-1.pdf Health Provider's Application for Authorization Under the Workers' Compensation Law
oc110a.pdf Claimant's Authorization to Disclose Workers' Compensation Records
oc110as.pdf Claimant's Authorization to Disclose Workers' Compensation Records (Spanish)
oc110AORD.pdf Request For Judicial Order - Access to Case Files
oc400.pdf Notice of Retainer and Substitution
oc400_1.pdf Attorney/ Representative's Application for Fee
oc400_5.pdf Attorney/Representative's Certification of Form C-3 Or C-7
oc401_1r.pdf Renewal Application for License to Appear on Behalf of Claimant
oc403_1.pdf Initial Application for License to Appear on Behalf of, or Represent, Carriers and/or Self-Insurers
oc403_1r.pdf Renewal Application for License to Appear on Behalf of, or Represent, Carriers and/or Self-Insurers
oc403_2.pdf Initial Application by Employee of Licensee under Sec 50 3-b or 50 3-d to Appear before the Workers' Compensation Board
oc403_2R.pdf Renewal Application by Employee of Licensee under Sec 50 3-b or 50 3-d to Appear before the Workers' Compensation Board
oc403_3.pdf Stockholder of Corporation Applying for License to Represent Self-Insurers Under Sec 50 3-b or 50 3-d Of The Workers' Compensation Law
oc406.pdf Notice of Retainer and Appearance on Behalf of Employer
oc407.pdf Self-Insurers' Representative's Bond
oc409.pdf Initial Application to Take License Representative Exam to Appear on Behalf of Claimants (SEC 24-A Of The Workers' Compensation Law), or to Appear on Behalf of or Represnet Carriers and/or Self Insurers
oc923.pdf Letter to New Employer re WC and DB Coverage
db680.pdf Insurance Carrier's Report of Claims Benefits, Employees and Covered Payrolls
otpt4.pdf Occupational/ Physical Therapist's Report
ph16_2.pdf Pre-Hearing Conference Statement
ps4.pdf Psychologist's Report
r.pdf Carrier's Report on Rehabilitation
rb89.pdf Application for Board Review
rb89_1.pdf Rebuttal of Application for Board Review
rb89_2.pdf Cover Sheet Application for Full Board Review
rb89_3.pdf Cover Sheet Rebuttal Of Application for Full Board Review
rfa-1LC.pdf Request for Further Action by Legal Counsel
rfa-1w.pdf Request for Assistance by Injured Worker
rfa-2.pdf Carrier's Employer's Request for Further Action
wtc-12.pdf Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL 162
wtc-12s.pdf Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL 162 (Spanish Version)
vaw1.pdf Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death
vaw3.pdf Volunteer Ambulance Worker's Claim for Benefits
vaw62.pdf Claim for Volunteer Ambulance Workers' Benefits in a Death Case
vaw501.pdf Volunteer Ambulance Workers Benefit Rates Death Benefits
vf-vaw-10.pdf Carriers Request for Benefit Increase Reimbursement under Section 51 Volunteer Firefighters and Volunteer Ambulance Workers Benefit Laws
vf-vaw-11c.pdf Volunteers Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV
vdf-1.pdf Loss of Wage Earning Capacity Vocational Data form
vdf1s.pdf Loss of Wage Earning Capacity Vocational Data form (Spanish)
vf1.pdf Notice to Political Subdivision of Volunteer Firefighter's Injury or Death
vf3.pdf Volunteer Firefighter's Claim for Benefits
vf62.pdf Claim for Volunteer Firefighter Benefits in a Death Case
vf501.pdf Volunteer Firefighters Benefit Rates Death Benefits
vbr1.pdf Application for Voluntary Binding Review
vbr2.pdf Voluntary Binding Review Parameters of Acceptance Agreement Section 32 WCL
w32_i.pdf WAMO Settlement Agreement Indemnity - Section 32 WCL
w32_im.pdf WAMO Settlement Agreement Indemnity/Medical - Section 32 WCL
wtcvol-3.pdf World Trade Center Volunteer's Claim for Compensation
wtc-16.pdf Cover Sheet: List of Itemized Medical Bills for Temporary Payment by the World Trade Center Volunteer Fund in Controverted World Trade Center Case
db-150.pdf Application for Self-Insurance for Disability Benefits
si-1.pdf Application for Self-Insurance
si-4.pdf Self-Insurer's Statement of Outstanding Death Claims (Print on 14" Paper)
si-4_1.pdf Self-Insurer's Statement of Outstanding Disability Claims (Print on 14" Paper)
si-4_11.pdf Instructions for Self-Insurer's Statement of Outstanding Death Claims and Instructions for Self-Insurer's Statement of Outstanding Disability Claims
si-6.pdf Self-Insurer's Report of Payroll For All Operations
si-10_1.pdf Self-Insurer's Report of Cumulative Compensation Payments
si-10_1m.pdf Self-Insurer's Report of Cumulative Medical Payments
si-21.pdf Certificate of Excess Insurance Contract for Self-Insurer
si-26.pdf Notice of Election by a Political Subdivision, Ambulance or Fire District (for Self-Insurance)
si-annual.pdf Self Insurer's Annual Update Form