Skip to Content

Workers' Compensation Board

Language Assistance: (877) 632-4996 | Language Access Policy
New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo


Subject No. 046-949

Revision of Employer's Statement of Wage Earnings (Form C-240)

Date: June 19, 2017

In claims where an injured worker may be entitled to compensation benefits or death benefits, employers must submit the injured worker's wage earnings information to the Board on the Employer's Statement of Wage Earnings (Form C-240) within 10 days of the Board's request. Form C-240 captures an injured worker's wage earnings information for the 52 weeks prior to the injured worker's date of injury or illness. This information is used to calculate the injured worker's average weekly wage and benefit rate.

If the injured worker did not work a substantial part of the year, Workers' Compensation Law Section 14(2) requires the employer to also provide the wage earnings of another worker of the same class who worked a substantial part of the year for the 52 weeks prior to the injured worker's injury date. A new Employer of the Same Class table has been added to Form C-240 to capture this payroll information when applicable. The phrase "substantial part of the year" does not refer to a specific number of days worked; however, the guideline of 234 days worked for a five-day worker and 270 days worked for a six-day worker may be used to determine if the injured worker has worked a substantial part of the year. The Board may find that an injured worker worked a substantial part of the year even if the injured worker did not work 234 or 270 days. [Matter of The Meadows at Westfall, Inc., 2013 NY Work Comp G0992183]

In lieu of completing the table(s) on page 2 of the form, detailed payroll information can be attached on a separate sheet or file (if submitting the form electronically). The employer must enter the total days paid and the total gross pay for the injured worker on Form C-240 in Questions 5 and 6.

Additional changes to Form C-240 include:

  • Question 1: added a check box for the employer to indicate whether they are attaching payroll documentation or completing the Injured Worker Payroll/Same Class Employee Payroll tables on page 2 of the form.
  • Question 4 (formerly Question 8): added the ability for the employer to explain if the worker does not work a five, six or seven day week.
  • Question 5: asks for the injured worker's total days paid in the preceding 52 weeks.
  • Question 6: asks for the injured worker's total gross pay, including overtime, in the preceding 52 weeks.
  • Question 7 (formerly Question 12, now combined with former Question 9): asks for wage adjustments, including military service during the 52-week period preceding the date of injury and the date of discharge.
  • Question 8: asks if the injured worker was laid off in the preceding 52 weeks.
  • Injured Worker Payroll table: clarified that the days paid should include paid time off.
  • New Worker of Same Class Payroll table: asks for the payroll information of a worker of the same class as the injured worker, if needed.
  • A barcode has been added to the bottom of the form to be used by the Board's scanning vendor.
  • New instructions for completing the form.

Employers must complete questions 1-8 on Form C-240 for the injured worker, as well as the Injured Worker Payroll table on page 2 of the form. Employers must also complete the new Employee of the Same Class section on page 2 of the form (worker of the same class payroll) in any case where the employer is uncertain whether the injured worker worked a substantial part of the year. When completing this section, employers should also write the name of the worker and that worker's title where indicated on the form. If the employer is submitting payroll documents in lieu of completing the payroll table(s), then page 2 of the form should not be included in the submission.

Form C-240 is available on the Board's website. Please see the Board's Forms page for submission options.

 

Kenneth J. Munnelly
Chair