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Glossary of WCB Terms

List of Available Forms


These forms are available for completion and online submission through the Board's web site.

The forms use Adobe Reader to render the form.  Adobe Reader® 9 or later, is recommended to support the additional functionality in this form. The latest version of Adobe Reader® Link to External Website is available as a free download from Adobe's web site.

After the Board receives your form, a non-editable PDF version of the form will appear in your web browser. The first page contains a confirmation that your form was successfully submitted to the Board and the date. It should be saved for your records. DO NOT MAIL THIS FORM TO THE BOARD.

If a confirmation page does not appear in your web browser after you submit the form to the Board, then the Board did not successfully receive the form and you will need to resubmit it.

New Adobe adobe pdf Format Overview/Features

Instructions for Attaching Documents

To access a form, select the form number or title. If registration is required, a login screen will prompt you for your user ID and password.

Complete the online application to register for Web Submission of Claim Forms.


Please Note: Effective 5/23/2014 the C-2, C-7. C-8/8.6, C-669, VF-2 and VAW-2 have been replaced by their EDI-equivalent FROI/SROI transactions and will no longer be accepted by the Board.

Forms Submitted by Attorneys and Licensed Representatives
Form Number Form Title Registration required? Comments
PH-16.2 Pre-Hearing Conference Statement No Filed ten days before scheduled pre-hearing conference for controverted (C-7) cases.
RFA-1LC Request for Further Action By Legal Counsel No The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORM C-89.3.

Note:When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name and date of injury.
VDF-1 Loss of Wage Earning Capacity Vocational Data Form No Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

 

Forms Submitted by Employers
Form Number Form Title Registration required? Comments
C-11 Employer's Report of Injured Employee's Change in Employment Status Resulting From Injury No As soon as employment status of injured employee changes.
C-240

Employer's Statement of Wage Earnings No Within 10 days of request by the Board.
PH-16.2

Pre-Hearing Conference Statement No Filed ten days before scheduled pre-hearing conference for controverted (C-7) cases.
RFA-2 Request for Further Action By Carrier/Employer No The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORMS C-89.3, C-22B, CB-8 AND RB-679.

Note: When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name and date of injury.

 

Forms Submitted by Health Care Providers
Form Number Form Title Registration required? Comments
C-4 Doctor's Initial Report Yes Use this form to report the first time you treated the claimant.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4 filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
C-4.2 Doctor's Progress Report Yes Use this form to report continuing services.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4.2 filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
C-4.3 Doctor's Report of MMI/Permanent Impairment Yes Note: The current electronic version of the C-4.3 will continue to be available for on-line submission. We plan to release the revised version on or before February 1, 2012.

Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4.3 filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
EC-4 AMR

Web Submission Process Overview
Ancillary Medical Report Yes This form may be used to file reports for ancillary medical services such as x-ray, pathology or diagnostic services by other than the attending provider in workers' compensation, volunteer firefighter's or volunteer ambulance workers' benefit cases.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4 AMR filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
EC-4NARR

Web Submission Process Overview
Doctor's Narrative Report Yes This form may be used to report the first time you treated the patient or to report continuing services. (To report permanent impairment,use Form C-4.3.)

Use this form only if attaching a detailed narrative report. See Attachment Requirements for topics that must be addressed in the narrative attachment.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4NARR filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).

OT/PT-4
Occupational Therapist's/ Physical Therapist's Report Yes 48 hour initial report, within 48 hours of first treatment.

15 day report, within 17 days of first treatment.

45 day progress report, at 45 day intervals while continuing treatment.

Every EOT/PT-4 filed with the Board is electronically signed by a NYS licensed occupational therapist or physical therapist in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).

 

Forms Submitted by Injured Workers
Form Number Form Title Registration required? Comments
C-3 Employee Claim No Must be filed within two years of injury, or within two years after employee knew or should have known that injury or illness was related to employment.
RFA-1W Request for Assistance By Injured Worker No The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORM C-89.3.

Note:When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, injured worker name and date of injury.
VDF-1 Loss of Wage Earning Capacity Vocational Data Form No Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

 

Forms Submitted by Insurance Carriers, Self-Insured Employers
and Third Party Administrators
Form Number Form Title Registration required? Comments
C-8.1 Notice of Treatment Issue(s)/ Disputed Bill Issue(s) Yes Treatment issue: within 5 days after terminating medical care or refusing authorization.

Disputed bill: within 45 days of submission of bill.
DB-470 Preliminary/Final Claim for Reimbursement of Benefits Paid Under Disability Benefits Law Yes Submitted prior to award of workers' compensation benefits.
PH-16.2 Pre-Hearing Conference Statement No Filed ten days before scheduled pre-hearing conference for controverted (C-7) cases.
RFA-2 Request for Further Action By Carrier/Employer No The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORMS C-89.3, C-22B, CB-8 AND RB-679.

Note: When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name and date of injury.

 

If the form you are looking for is not available for online submission, you may print the PAPER version of the form from our list of common forms.