New York State
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
20 Park Street Albany, New York 12207
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
20 Park Street Albany, New York 12207
David A. Paterson
Governor
Subject No. 046-1.14
Governor
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 (www.wcb.ny.gov) under the heading Forms. For information on any Board form, contact the Board's Forms Department at FormsDepartment@wcb.ny.gov.
Forms Department
| FORM NO. | TITLE | DATE |
|---|---|---|
| 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-110AS | AUTORIZACIÓN DE RECLAMANTE PARA PERMITIR ACCESO A EXPEDIENTES ANTE LA JUNTA (Spanish OC-110A) | 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 |
| 