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Workers' Compensation Board

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New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Subject No. 046-118

Application for Advance of Periodic Payments of Compensation
Revised Form C-21

Date:  September 10, 2003

Section 25(5)(b) of the Workers' Compensation Law permits the Board, upon application of the claimant, to commute periodic continuing payments of compensation into one or more lump sum payments when to do so would be in the interest of justice. Form C-21, Application for Advance of Periodic Payments of Compensation (formerly titled Application for Lump Sum Payment), is used for this purpose. Form C-21 should only be filed after the claim has been finalized with a direction from the Board for continuing payments to the claimant.

Form C-21 (8-03) has been revised and expanded to solicit additional information from the claimant regarding income, expenses, dependents, liens, etc., to assist the Board in evaluating the need for an advance in payments.

Upon receipt of Form C-21, a Board Social Worker will contact the claimant to go over the application and discuss actuarial credit, compensation adjustment and other financial issues, if any, and will request additional information and documentation from the claimant, if needed. Such documentation may include verification of debt, proof of household income, sales contracts for large purchases or price estimates for home improvements, etc.

If the application is in order and all information is available, the Board Social Worker will send new Form C-21.1 to the carrier, advising the carrier of the amount of advance payment requested and to begin the process of actuarial computation based on this amount. The carrier must return Form C-21.1 to the Board within 10 days indicating in the space provided whether the request for advance is approved or disapproved. If the form is not returned within 10 days the carrier's right to disapprove is waived. The Social Worker will forward the application to the Board's Office of Appeals with his/her recommendation for approval or disapproval of the request. The Office of Appeals will issue the written decision of the Board to all parties.

If at any time after filing Form C-21 the claimant withdraws the application, new Form C-21.2 will be sent to all parties advising them of the withdrawal.

Revised Form C-21 is available on the Board's website ( under the heading "Common Forms Online." It can also be obtained at any office of the Workers' Compensation Board.

Thank you for your cooperation.


Jeffrey R. Sweet
Acting Chairman