Workers' Compensation Coverage
What To Do When An Accident Happens
The Path of a Claim
The worker obtains the necessary medical treatment and notifies his/her supervisor about the accident and how it occurred.
The employee notifies the employer of the accident in writing, as soon as possible, but within 30 days. The Board can excuse the lack of notice if notice couldn't be given, the employer had knowledge, or if the employer is not harmed by lack of notice (WCL §18).
The employee may file a claim with the Board on Employee Claim (C-3) [ On-line C-3 ] , by filing the form with the Board. This must be done within two years of the accident, or within two years after the employee knew or should have known, that the injury was related to employment (WCL §28).
The doctor completes a preliminary medical report on Doctor's Initial Report (C-4) and mails it to the appropriate District Office. Copies must also be sent to the employer or its insurance carrier, the injured worker, and his/her representative, if any (WCL §13-a [a]).
The employer reports the injury to the insurance company. (WCL §110 ).
The insurer provides the injured worker with a written statement of his/her rights under the law (Statement of Rights (C-430S) ). This must be done within 14 days after employers’ notification of injury/illness or with the first check, whichever is earlier (WCL §110 ). If the insurer requires the injured worker to use a provider within a network for diagnostic tests it must provide the injured worker with the name and contact information from the network (WCL §13-a[b]).
Within 18 days after the first day of disability or 10 days after the employer first has knowledge of the alleged accident, or within 10 days after the employers’ notification of injury/illness, whichever is greater:
The insurer begins the payment of benefits if lost time exceeds seven days. If the claim is being disputed, the insurer must inform the Workers' Compensation Board (and the claimant and his/her representative, if any). If the claim is not disputed, but payment is not being made for specific reasons stated on the notice, (e.g. that there is no lost time or that the duration of the disability is less than the 7-day waiting period), the insurer must also notify all the parties (WCL §25  and 12 NYCRR §300.22) .
The insurer files the appropriate FROI or SROI transaction with the Board indicating either that payment has begun or the reasons why payments are not being made. A copy of the FROI or SROI transaction must be transmitted to the claimant and his/her attorney/licensed representative, if any, simultaneously with the filing with the Board. If the employee does not notify the employer timely, this notice may be filed within 10 days of learning of the accident.
Where controverted – When the Board notifies an employer or its insurance carrier that a workers' compensation case has been indexed against the employer, and the employer or insurance carrier decides to controvert the claim, a notice of controversy shall be filed with the Board within 25 days from the date of mailing of the notice of indexing. Failure to file the notice of controversy within the prescribed 25 day time limit could bar the employer and its carrier from pleading certain defenses to the claim (WCL §25[b]).
Where not controverted – If the right to compensation is not controverted but payment has not begun because no compensation is presently due, a partial denial shall be filed with the Board not later than 25 days after the Board has transmitted a notice of indexing a case to the employer or its insurance carrier.
The insurer continues to make payments of benefits to the injured employee (if the case is not being disputed). The carrier must notify the Board with a SROI transaction when compensation is stopped or modified (WCL §25 [d]).
The doctor submits progress reports following every treatment on Doctor's Progress Report (C-4.2) to the Board.
The insurer considers the necessity of rehabilitation treatment for the injured employee (Carrier's Report on Rehabilitation (R) ).
Notices of hearings will ordinarily be sent by The Board to the carrier for the employer, or directly to the employer if self-insured. An employer having knowledge of a hearing is not obligated to attend unless a hearing notice is sent to the employer, specifically requesting attendance, or unless a representative of insurance carrier requests attendance.