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Workers' Compensation Board

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New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
David A. Paterson

Subject No. 046-1.14

New and Revised Prescribed Workers' Compensation Board Forms

12-1-08 through 8-31-09

Date: September 2, 2009

The table below shows prescribed Workers' Compensation Board forms that have been recently issued or revised. Most of these forms are available on the Board's website ( under the heading Forms. For information on any Board form, contact the Board's Forms Department at

Forms Department


Recently Issued or Revised Prescribed Workers' Compensation Board Forms
12-1-08 through 8-31-09
ADR-1 Alternative Dispute Resolution Program Report of Injury 8-09
ADR-1.1 Alternative Dispute Resolution Program: Modification of Previous Report 8-09
ADR-2 Alternative Dispute Resolution Program Final Disposition or Settlement of Claim 8-09
AFF-1 Affidavit for Death Benefits 8-09
AFF-2 Affidavit for Death Benefits (Dependent Brothers/Sisters/Grandchildren) 8-09
AFF-3 Affidavit for Death Benefits (Dependent Parents/Grandparents) 8-09
C-2 Employer's Report of Work-Related Injury/Illness 8-09
C-3 Employee Claim 8-09
C-3S Reclamación del Empleado (Spanish version of Form C-3) 8-09
C-4 Doctor's Initial Report 8-09
C-4 AMR Ancillary Medical Report 8-09
C-4 AUTH Attending Doctor's Request for Authorization and Carrier's Response 8-09
C-4.2 Doctor's Progress Report 8-09
C-4.3 Doctor's Doctor's Report of MMI/Permanent Impairment 8-09
C-5 Attending Ophthalmologist's Report 8-09
C-7 Notice That Right to Compensation is Controverted 8-09
C-8/8.6 Notice That Payment of Compensation Has Been Stopped or Modified 8-09
C-8.1 Notice of Treatment Issue/Disputed Bill 8-09
C-11 Employer's Report of Injured Employee's Change in Status or Return to Work 8-09
C-21 Application for Advance on Periodic Payments of Compensation 8-09
C-22 Application for Approval of Non-Schedule Adjustment 8-09
C-25 Application for Reopening of Claim, More Than Seven Years After Accident 8-09
C-27 Medical Proof of Change in Condition in Support of Application for Reopening 8-09
C-32.1 Section 32 Settlement Agreement: Claimant Release 8-09
C-34 Notice to Show Proof of Compliance with the Workers' Compensation Law 7-09
C-62 Claim for Compensation in Death Case 8-09
C-64 Proof of Death by Physician Last in Attendance on Deceased 8-09
C-65 Proof of Burial and Funeral Expenses by Undertaker 8-09
C-105 Notice of Compliance – Workers' Compensation Law 8-09
C-121 Claim for Compensation and Notice of Commencement of Third Party Action 8-09
C-240 Employer's Statement of Wage Earnings Preceding Date of Accident 8-09
C-251.3 Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) and Section 15(8) 8-09
C-430S Statement of Rights (WCL) 8-09
C-669 Notice to Chair of Carrier's Action on Claim for Benefits 8-09
CE-200 APPLY Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage 12-08
DB-102 Information for Employer Regarding Disability Benefits Law 7-09
DB-118 Employer's Statement for the Purpose of Terminating Status as a Covered Employer 7-09
DB-120 Notice of Compliance – Disability Benefits Law 8-09
DB-120.10 Gummed Label for Use with Form DB-120 Upon Renewal of Policy 1-09
DB-155 Compliance With Disability Benefits Law (Self-Insurer) 7-09
DB-271S Statement of Rights (DBL) 8-09
FCE-4 Practitioner's Report of Functional Capacity Evaluation 8-09
HIMP-1 Health Insurer's Request for Reimbursement 1-09
IME-3 Practitioner's Report of Request for Information/Response to Request Regarding Independent Medical Examination 8-09
IME-4 Practitioner's Report of Independent Medical Examination 8-09
IME-5 Claimant's Notice of Independent Medical Examination 8-09
MD-1 Attending Doctor's Request for Medical Authorization Determination 8-09
MD-3 Carrier/Board-approved self-insured employer's Objection to Attending Doctor's Request for Medical Authorization Determination 8-09
OC-110A Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) 8-09
OC-400 Notice of Retainer and Substitution 8-09
OC-400.1 Attorney/ Representative's Application for Fee 8-09
OC-400.5 Attorney/ Representative's Certification of Form C-3 or C-7 3-09
OC-923 Important Information for Employers Operating in New York State 7-09
OT/PT-4 Occupational/ Physical Therapist's Report 8-09
PH-16.2 Pre-Hearing Conference Statement 8-09
PS-4 Psychologist's Report 8-09
RB-89 Cover Sheet – Application for Board Review 8-09
RB-89.1 Cover Sheet – Rebuttal of Application for Board Review 8-09
RB-89.2 Cover Sheet – Application for Full Board Review 8-09
RB-89.3 Cover Sheet – Rebuttal of Application for Full Board Review 8-09
RFA-1 Claimant's Request for Further Action 8-09
RFA-2 Carrier's/Employer's Request for Further Action 8-09
SI-12 Affidavit Certifying That Compensation Has Been Secured (Self-Insurer) 7-09
VAW-2 Political Subdivision's Report of Injury to Volunteer Ambulance Worker 8-09
VAW-3 Volunteer Ambulance Worker's Claim for Benefits 8-09
VAW-62 Claim for Volunteer Ambulance Workers' Benefits in a Death Case 8-09
VAW-105 Notice of Compliance – Volunteer Ambulance Workers' Law 8-09
VF-2 Political Subdivision's Report of Injury to Volunteer Firefighter 8-09
VF-3 Volunteer Firefighter's Claim for Benefits 8-09
VF-62 Claim for Volunteer Firefighter Benefits in a Death Case 8-09
VF-105 Notice of Compliance - Volunteer Firefighters Benefit Law 8-09
VF/VAW-11C Volunteer's Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV Per VFBL/VAWBL Section 11-c(1) 8-09
WTC-12 Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL §162 8-09