Workers' Compensation Board Common Forms
Forms are in PDF format. The Board recommends using the
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which is available as a free download from Adobe's web site.
After the form opens in your browser, you may complete the form by typing information on the form before you print it.
IMPORTANT: Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.
If you require assistance with completing these forms, please contact your local WCB District Office.
Please note: Forms C-105, C-105.1, C-105.2, DB-120 and DB-120.1 are not available on this site. Contact your insurance carrier or licensed NYS insurance agent for these forms. Carriers and their licensed agents may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
| Form Number / Version Date |
Form Title | Who Files | Where to File | When to File |
|---|---|---|---|---|
| A-9 (1/07) A-9S (Spanish version) on reverse |
Notice that You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim is Disallowed, or if Agreement Pursuant to WCL §32 is Approved | Employee | File with Health Provider | Health providers are permitted to obtain the claimant's agreement to pay usual and customary fees in the event claim is not prosecuted or is disallowed. Form should be retained by doctor after it is completed and signed. |
| ADR-1 (1/11) | Alternative Dispute Resolution Program Report of Injury | Employers Participating in the Alternative Dispute Resolution Program | Workers' Compensation Board | Within 10 days of a work-related injury or illness. Note: Print form on WHITE paper, not green. |
| ADR-1.1 (1/11) | Alternative Dispute Resolution Program: Modification of Previous Report | Employers Participating in the Alternative Dispute Resolution Program | Workers' Compensation Board | Whenever it is necessary to modify, clarify or update information reported on any previously filed ADR form. |
| ADR-2 (1/11) | Alternative Dispute Resolution Program Final Disposition or Settlement of Claim | Employers Participating in the Alternative Dispute Resolution Program | Workers' Compensation Board | Within 30 days of final disposition or settlement of the claim. Note: Print form on WHITE paper, not green. |
| AFF-1 (1-11) | Affidavit For Death Benefits | Claimant (see when to file) | Workers' Compensation Board | This affidavit is to be used by a surviving spouse or the dependent child(ren) of the deceased; by dependent brothers/sisters/grandchildren; by dependent parents/grandparents. It can also be used by the non-dependent parents or the estate of the deceased where there is no surviving spouse or other dependents. |
| AFF-2 (obsolete) |
Affidavit For Death Benefits (Dependent Brothers/Sisters/Grandchildren) | Form AFF-1 can now be used for all claims previously filed on forms AFF-2 and AFF-3 | ||
| AFF-3 (obsolete) |
Affidavit For Death Benefits (Dependent Parents/Grandparents) | Form AFF-1 can now be used for all claims previously filed on forms AFF-2 and AFF-3 | ||
| BP-1 (12/08) | Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence | Homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence who are serving as their own general contractor on small jobs that require a building permit may be eligible to fill out this form as proof that they do not need a statutory workers' compensation policy (See BP-1 Cover Letter) | Generally, the homeowner will file the BP-1 form with a municipal building department | When the homeowner is listed as the general contractor on a building permit and is in the process of obtaining that building permit |
| C-2 (1/11) Paper Version [C-2 On-line Submissions] [C-2 Instructions] |
Employer's Report of Work-Related Injury/Illness | Employer | Workers' Compensation Board, copy to insurance carrier. | Within ten days after occurrence of Injury/Illness. |
| CLAIMANT INFORMATION PACKET (which includes the two sided document, a C-3 form and C-3.3 form) Compendio Información Reclamante (Claimant Information Packet, Spanish) |
CLAIMANT INFORMATION PACKET (which includes the two sided document, a C-3 form and C-3.3 form) |
Employers or their designees, such as third-party administrators or insurance carriers. (Note: The Claimant Information Packet is not filed with the Board) | Provided to an injured worker immediately after a work-related accident or exposure. | When an employee is injured due to a work-related accident or becomes ill due to exposure, the employer or its designee must provide the injured worker with the Claimant Information Packet as soon as possible. The employer or its designee must note on the C-2 form that the packet was given to the injured worker. |
| C-3 (1/11) Paper Version
[C-3 On-line Submission] [C-3 Instructions] |
Employee Claim | Employee | Workers' Compensation Board, in the event of on-the-job injury or illness. | Within two years of accident, or within two years after employee knew or should have known that injury or illness was related to employment. |
| C-3S (1/11) | Reclamación del Empleado | Empleado | Junta de Compensación Obrera, en la eventualidad de lesión en el trabajo ó enfermedad. | Dentro del término de dos años del accidente, o dentro del término de dos años después que el empleado supo ó debió saber que la lesion o enfermedad estaba relacionada con el trabajo. |
| C-3.1 (3/04) C-3.1S (Spanish version) on reverse |
Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider | Employee | Completed by injured employee when employer who is not part of a PPO or ADR program wishes to recommend a network or provider to such employee for treatment purposes. The form is maintained by employer and is not submitted to the Board. | The consent shall not be executed prior to the occurrence of employee's work-related injury or illness, but must be executed prior to an employer, who is not part of a PPO or ADR program, recommending a network or provider to an injured employee for treatment purposes. |
| C-3.3 (12/09) | Limited Release of Health Information (HIPAA) | Claimant | Workers' Compensation Board | If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current Claim, fill out this form. |
| C-4 (1/11) Paper Version [C-4 On-line Submission] See Subject No. 046-398 — Authorized Provider Shortage in Rochester Area; Temporary Change in Medical Reporting Requirements |
Doctor's Initial Report | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | This form is filed within 48 hours of first treatment. To report continued treatment, use Form C-4.2. To report permanent impairment use Form C-4.3. |
| C-4.1 (9/08) | Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4 | Health Provider | See Form C-4. This form must be attached to and filed with Form C-4. (May also be used with Forms C-4.2, C-4.3, C-5, PS-4 and OT/PT-4) | See Form C-4. Use as continuation sheet when more than six dates of service must be shown in the billing portion of Form C-4. (May also be used with Forms C-4.2, C-4.3, C-5, PS-4 and OT/PT-4) |
| C-4.2 (1/11) Paper Version [C-4.2 On-line Submission] |
Doctor's Progress Report | Health Care Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | This form is used for the 15 day report after first treatment, and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart. To report the first time you treated claimant use Form C-4. To report permanent impairment use Form C-4.3. |
| C-4.3 (1/11) Paper Version [C-4.3 On-line Submission] |
Doctor's Report of MMI/Permanent Impairment | Health Care Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment. |
| C-4 AMR (1/11) Paper Version [EC-4 AMR On-line Submission] |
Ancillary Medical Report | Provider Other than the Attending Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | As soon as possible after ancillary treatment or services (such as radiology, pathology or diagnostic services) are rendered. |
| C-4 AUTH (1/11) |
Attending Doctor's Request for Authorization and Carrier's Response | Health Care Provider | Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. If the patient is represented by an attorney or licensed representative send a copy to such legal representativeIf the patient is not represented, a copy must be sent to the patient. | This form is used to confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation. |
| EC-4NARR (12/10) On-line Submission |
Doctor's Narrative Report | Health Care Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | Use this form to report first treatment; for the 15 day report after first treatment; and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart. services. To report permanent impairment use Form C-4.3.
Use this form only if attaching a detailed narrative report. See Attachment Requirements for topics that must be addressed in the narrative attachment. |
| C-5 (1/11) | Attending Ophthalmologist's Report | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative. | 48 hour initial report, within 48 hours of first treatment. 15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
| C-7 (1/11) Paper Version [C-7 On-line Submission] |
Notice That Right to Compensation is Controverted | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to employee and his/her representative, and all health providers . | On or before 18th day after disability or within 10 days after employer had knowledge of injury, whichever is greater or if the first notice of the accident or illness is a notice of indexing, then within 25 days of receipt of the notice of indexing. |
| C-8/8.6 (1/11) Paper Version [C-8/8.6 On-line Submission] |
Notice That Payment of Compensation Has Been Stopped or Modified | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to employee and his/her representative. | Within 16 days after the date on which benefit payments were stopped or modified. |
| C-8.1 (1/11) Paper Version [C-8.1 On-line Submission] |
Notice of Treatment Issue/Disputed Bill | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to employee and his/her representative, and health provider. | Treatment issue: within 5 days after terminating medical care or refusing authorization. Disputed bill: within 45 days of submission of bill. |
| C-8.4 (1/11) | Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s) | Carrier/Self-Insured Employer | Health Care Provider, Workers' Compensation Board, Claimant and his/her representative, if any. | This form must be used for valuation objections except when the amount billed for the particular CPT code is in excess of the amount designed by the workers' compensation fee schedule, and the carrier pays the bill at the appropriate fee schedule amount. |
| C-11 (1/11) Paper Version [C-11 On-line Submission] |
Employer's Report of Injured Employee's Change in Status or Return to Work | Employer | Workers' Compensation Board | As soon as employment status of injured employee changes. |
| C-21 (1/11) | Application for Advance on Periodic Payments of Compensation | Claimant | Workers' Compensation Board | See instructions on form. The application will only be considered if the claim has been finalized with the direction by the Board for continuing payments to the claimant. |
| C-22 (1/11) Note: Print form on 14 inch paper. |
Application for Approval of Non-Schedule Adjustment | Employee and Carrier/Board-approved self-insurer | Workers' Compensation Board (One copy only: quadruplicate filing is no longer required.) | This is a joint application by employee and carrier/employer to close case on a non-schedule adjustment. It must be signed by all parties in the case. |
| C-25 (1/11) | Application for Reopening of Claim, More Than Seven Years After Accident | Employee | Workers' Compensation Board | When applying to reopen case more than seven years after date of accident. File with Form C-27 doctor's report (see below) if required. |
| C-27 (1/11) | Medical Proof of Change in Condition in Support of Application for Reopening | Health Provider | Workers' Compensation Board, with copy to insurance carrier, if known, or employer. | File in a closed case to show change in medical condition supporting reopening of claim. |
| C-32 (11/09) | Settlement Agreement, Section 32 |
Parties in Interest | Form must be signed by all parties in interest and mailed to WCB (or presented at hearing). | Agreement may be filed at any time during an open and pending case, and may cover any and all issues. |
| C-32.1 (1/11) | Section 32 Settlement Agreement: Claimant Release | Party Submitting Section 32 Settlement Agreement | Workers' Compensation Board | Completed and notarized Form C-32.1 must be filed along with Form C-32, Settlement Agreement. |
| C-34 (7/09) | Notice to Show Proof of Compliance with the Workers' Compensation Law | Government agencies will issue this form to employers that do not have proper proof that they have
obtained workers' compensation and disability benefits insurance, and/or have not displayed the proper
postings of workers' compensation and disability benefits coverage. Employers must then complete Form
C-34 and return it to the Workers' Compensation Board per the instructions on the form. Government agencies may order blank C-34 forms from the Forms Department. |
Employers that were issued Form C-34 by a government agency must complete the form and return it to the Workers' Compensation Board per the instructions on the form. | Employers must file Form C-34 with the Board within ten days of being issued the notice by a government agency. |
| C-62 (1/11) | Claim for Compensation in Death Case | Claimant (The claimant is the surviving spouse, child or dependent of the deceased. See the reverse of the form for details on who may file a claim in a death case.) | Workers' Compensation Board in the event of on-the-job death. | Within two years of accidental death. |
| C-64 (1/11) | Proof of Death by Physician Last in Attendance on Deceased | Health Provider | Workers' Compensation Board and insurance carrier/Board-approved self-insurer | Upon death of claimant, or when requested by WCB |
| C-65 (1/11) | Proof of Burial and Funeral Expenses by Undertaker | Undertaker | Workers' Compensation Board | When requested by WCB |
| C-72.1 (1/12) | Record of Percentage Hearing Loss | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative. | Upon completion of audiometric test battery. |
| C-89.3 (11/01) (obsolete) |
Replaced by Form RFA-1 (for claimants/claimants' representatives) OR RFA-2 (for carriers/Board-approved self-insurers) | |||
| C-105 (1/11) | Notice of Compliance – Workers' Compensation Law | Employers insured for workers' compensation through an insurance carrier or Board-approved self-insurance | This form is not filed. It must be completed by the insurance carrier, self-insured administrator or the Board's Self-Insurance Office with identifying insurance information and then displayed by the employer in the workplace. | Upon securing of workers' compensation insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent. Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. Refer to Subject No. 046-308 for revised printing specifications for Form C-105. |
| C-105.1 (9-05) | Notice to Be Posted by Employers Under WCL for Automotive or Horse–Drawn Vehicles | Employers insured for workers' compensation through an insurance carrier or Board-approved self-insurance | This form is not filed. It must be completed by the insurance carrier, group Board-approved self-insurance administrator or Board-approved self-insured employer with identifying insurance information and then displayed by the employer in automotive or horse-drawn vehicles in accordance with Section 51 WCL. | Upon securing of workers' compensation insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent. Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
| C-105.2 (9/07) | Certificate of NYS Workers' Compensation Insurance Coverage (All private NYS licensed workers' compensation carriers are required to issue the C-105.2. Please note that the State Insurance Fund issues a different form, the U-26.3 form, as its version of the C-105.2) | Employers insured for workers' compensation through a private insurance carrier | Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The C-105.2 must be completed by the insurance carrier or its licensed insurance agent. | Employers must obtain this form from either their NYS workers' compensation insurance carrier or a licensed NYS insurance agent of that carrier. Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
| C-105.10 (9-05) | Gummed Label for Use with Form C-105 Upon Renewal of Policy | NOT FILED | This label is placed over the expired policy information on the bottom of Form C-105. | Upon renewal of a workers' compensation insurance policy, a carrier may issue this label with updated policy information in lieu of issuing an entire new Form C-105 poster, as long as the current version of Form C-105 is already being used.Employers must obtain this form from their insurance carrier or licensed agent. Board-approved self-insurers may contact the Board's Forms Department. |
| C-105.11 (11-10) | Consent to NYS Workers' Compensation Board Jurisdiction for non-New York Licensed Carriers (3C Coverage) | Insurance Company not authorized by NYS Insurance Department to write workers' compensation and employers' liability insurance in New York | With the Chair of the WCB by sending to Bureau of Compliance at 20 Park Street, Albany, NY 12207 | When an insurance company not authorized by NYS Insurance Department to write workers' compensation and employers' liability insurance issues policy to employer not required to have a full statutory New York policy and New York is listed in Item 3C of the Information Page. |
| C-105.21 (11/01) (obsolete) |
See Form CE-200 | |||
| C-105.31 (1/04) | Notice of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL | Municipal Corporation or Political Subdivision | File with insurance carrier. | File with insurance carrier. |
| C-105.32 (4/04) | Notice of Election of a Partnership, Limited Liability Partnership, Professional Limited Liability Partnership, Limited Liability Company, Professional Limited Liability Company or Sole Proprietorship to Bring Partners, Members or Self-Employed Persons Under the Coverage of the New York State Workers' Compensation Law | Partnership or Sole Proprietorship | File with insurance carrier. | File with insurance carrier. |
| C-105.41 (1/04) | Revocation of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL | Municipal Corporation or Political Subdivision | File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau, 20 Park St., Albany, NY 12207., and to each officer named on form. | Revocation is effective 30 days after date filed with WCB and insurance carrier. |
| C-105.51 (1/04) | Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage | Sole Shareholder Officer or Two Executive Officers of a corporation required to have workers' compensation coverage | File with insurance carrier. Board-approved self-insured employers file with the WCB Self-Insurance Office. Board-approved group self-insured's file with the WCB Self-Insurance Office and also with your Group Administrator. | As soon as the corporation wishes to exclude the sole shareholder-officer, or one of the two or both executive officers-shareholders of the corporation from workers' compensation coverage. |
| C-105.52 (1/04) | Notice of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage | Not-for-Profit Corporation or Unincorporated Association | File with insurance carrier. | Unsalaried executive officer is deemed included in insurance contract until election to exclude is filed. |
| C-105.53 (1/04) | Revocation of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage | Not-for-Profit Corporation or Unincorporated Association | File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau, 20 Park St., Albany, NY 12207. | Revocation is effective 30 days after the date filed by the corporation or association with the insurance carrier and the WCB. |
| C-105.54 (3/99) | Notice of Election to Bring Sheltered Workshop Participants Under Coverage of WCL | Office or agency operating sheltered workshop | File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau, 20 Park St., Albany, NY 12207. | File with insurance carrier. |
| C-105.55 (1/04) | Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage | Sole Shareholder Officer or Two Executive Officers of a corporation required to have workers' compensation coverage | File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau, 20 Park St., Albany, NY 12207. If Board-approved self-insured employer, to WCB only. | Upon deciding to revoke election to exclude officer(s) from coverage. |
| C-107 | Employer's Request for Reimbursement (NY State Insurance Fund) |
This is a New York State Insurance Fund form. If you are an employer insured by the NY State Insurance Fund, contact your local State Insurance Fund office for this form, or call toll-free 888-875-5790. | ||
| C-121 (1/11) | Claim for Compensation and Notice of Commencement of Third Party Action | Employee | Workers' Compensation Board, the employer and insurance carrier. | Within 30 days after third party action has been commenced. |
| C-240 (1/11) Paper Version [C-240 On-line Submission] |
Employer's Statement of Wage Earnings Preceding Date of Accident | Employer | Workers' Compensation Board | Within 10 days of request by the Board. |
| C-250 (3/07) | Notice of Claim for Reimbursement Out of Special Disability Fund Under Section 15-8 | Insurance Carrier/Board-approved Self-Insurer | Original and one copy to WCB Finance Office, 20 Park St. Room 301, Albany NY 12207 A check for $250, payable to "Special Disability Fund", must be included with each claim. |
Prior to final determination that disability is permanent, but in no case more than 104 weeks after the date of disability or death, or 52 weeks after the date that a claim for compensation is filed with the chair, whichever is later. |
| C-251 (11/01) Form must be printed on yellow paper. |
Carrier's Request for Reimbursement of Compensation Payments Under Section 15-8 | Insurance Carrier/Board-approved self-insurer | Local office of Special Funds Conservation Committee; copy to Finance Office, WCB, 20 Park Street, Albany NY 12207 | For twenty-six week periods, if possible. |
| C-251.1 (11/01) Form must be printed on pink paper |
Carrier's Request for Reimbursement of Medical Expenses Under Section 15-8 | Insurance Carrier/Board-approved self-insurer | Local office of Special Funds Conservation Committee; copy to Finance Office, WCB, 20 Park Street, Albany NY 12207 | For twenty-six week periods, if possible. |
| C-251.2 (11/01) Form must be printed on blue paper |
Carrier's Request for Reimbursement of Compensation Payments Under Section 14(6) Concurrent Employment | Insurance Carrier/Board-approved self-insurer | Local office of Special Funds Conservation Committee; copy to Finance Office, WCB, 20 Park Street, Albany NY 12207 | For twenty-six week periods, if possible. |
| C-251.3 (1/11) | Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) and Section 15(8) | Insurance Carrier/Board-approved self-insurer | Original to Workers' Compensation Board (to be filed in case); One copy to WCB Finance Office, 20 Park St. Albany NY 12207; retain one copy for your records. | Notice must be filed prior to the decision making an award. |
| C-257 (9/10) | Claimant's Record of Medical and Travel Expenses and Request for Reimbursement | Claimant | Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. | As needed. Include copies of all receipts and bills, if possible. |
| C-258 (8/10) | Claimant's Record of Job Search Efforts/Contacts | Unemployed claimant classified as having a permanent partial disability | Do not send this form to the Workers' Compensation Board or the insurance carrier. You may be asked to present a list to evaluate your work search efforts at a hearing. | This form is to assist you in an independent job search. List all the employers, employment agencies and labor unions you have contacted while receiving workers' compensation benefits. |
| C-300.34 (10/97) | Statement of Unresolved Issues (Special Part for Expedited Hearings) | Parties in Interest | Workers' Compensation Board, with copies to all other parties in interest. | Within 20 days after case is ordered transferred to the Special Part for Expedited Hearings. |
| C-300.5 (7/97) | Stipulation | Employee (and Attorney or Representative, if represented) and Carrier/Board-approved self-insurer | Workers' Compensation Board | To be used for stipulations to uncontested facts or proposed findings, pursuant to 12NYCRR 300.5. |
| C-312.5 (12/10) | Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only) | Claimant (if represented) and Carrier/Board-approved self-insurer | Workers' Compensation Board | In cases where the claimant is represented, this form is to be used by the parties to propose findings and awards pursuant to 12NYCRR 312.5. |
| C-430S (1/11) | Statement of Rights (WCL) | Insurance Carrier/Board-approved self-insurer | Sent to injured employee. | Within 14 days of receipt of Form C-2 from employer, or with initial benefit check, whichever is earlier. |
| C-669 (1/11) Paper Version [C-669 On-line Submission] |
Notice to Chair of Carrier's Action on Claim for Benefits | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, with copy to claimant and his/her representative. | IF PAYMENT HAS BEGUN: on or before 18th day after disability, or within 10 days after employer first had knowledge of injury, whichever is greater. IF PAYMENT HAS NOT BEGUN: no later than 25 days after the Board has mailed a Notice of Indexing. |
| C-DB-22 | Employer's Statement (for Form DB-450) (NY State Insurance Fund) | This is a New York State Insurance Fund form. The State Insurance Fund has pre-printed Form DB-450 with the Employer's Statement on the reverse. |
||
| CB-11 (11/06) | Claimant's Guide to the Conciliation Process | N/A | N/A | This is an informational form that the Board uses to advise claimants and insurance carriers of their rights and responsibilities in the Conciliation Process. |
| CB-11S (1/07) | Guia Para Reclamantes Sobre El Proceso De Conciliación | N/A | N/A | Esta es una forma informativa que la Junta utiliza para orientar a los reclamantes de sus derechos y responsabilidades en el Proceso de Conciliación. |
| CE-200 (12/08) (Replaces WC/DB-100 and Form C-105.21) |
Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage | Applicants for permits, licenses or contracts from State, county or municipal agencies in New York State that are not required to carry NYS workers' compensation and/or disability benefits insurance coverage. | Please file with the government agency that is issuing the permit, license or contract. (Examples: The New York City Department of Buildings or the New York State Department of Health) | These exemption forms can ONLY be used to attest to a government entity that an applicant requesting a permit, license or contract from that government entity is not required to carry NYS workers' compensation and/or disability benefits insurance. (Instructions) |
| CE-200 APPLY (2/09) Used as a paper application for Form CE-200 which replaces Forms WC/DB-100 and C-105.21. |
Paper application for the CE-200, Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage | A paper application to obtain the CE-200. The CE-200 is used by the applicant to certify they are not required to carry workers' compensation and/or disability benefits when obtaining a license,permit , or contract from State, county or municipal agencies in New York State. Applicants using this paper application process may wait up to four weeks before receiving a CE-200. This delay results from Workers' Compensation Board staff having to manually enter information from the applicant's paper application into the web based application. Accordingly, to avoid delays, all applicants for exemptions are strongly encouraged to use the on-line Form CE-200. |
Mail the completed CE-200 APPLY application to:
NYS WCB Bureau of Compliance Form CE-200 100 Broadway Albany, NY 12241-0005 or Fax: 800-486-7175 Once the applicant receives the CE-200, the applicant can then verify the information on the CE-200, sign it and then submit that CE-200 to the government agency from which he/she is getting the permit, license or contract. |
Please also print the related instructions for filling out Form CE-200 APPLY (Instructions) |
| DB-102 (7/09) | Information for Employer Regarding Disability Benefits Law | General DBL information made available to the public. | Not filed | Not filed |
| DB-118 (7/09) | Employer's Statement for the Purpose of Terminating Status as a Covered Employer | Employer | In TRIPLICATE to: NYS Workers' Compensation Board Disability Benefits Bureau 100 Broadway Albany, NY 12241 |
After the end of any calendar year in which the employer did not employ one or more employees on each of thirty days |
| DB-120 (1/11) | Notice of Compliance - Disability Benefits Law | Employers insured for disability benefits through an insurance carrier or Board-approved self-insurance. | This form is not filed. It must be completed with identifying insurance information and displayed in the workplace. | Upon securing of disability benefits insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent. Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
| DB-120.1 (5/06) | Certificate Of Insurance Coverage Under The NYS Disability Benefits Law | Employers insured for NYS statutory disability benefits insurance through an insurance carrier. | Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The DB-120.1 must be completed by either the NYS statutory disability benefits insurance carrier, or a licensed NYS insurance agent of that carrier. | Employers must obtain this form from either their NYS statutory disability benefits insurance carrier or a licensed NYS insurance agent of that carrier. Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
| DB-120.10 (1/09) | Gummed Label for Use with Form DB-120 Upon Renewal of Policy | Not Filed | Upon renewal of a policy, employers receive this gummed label from their disability benefits insurance carrier. Employers then place the DB-120.10 label over the expired policy information on the bottom of Form DB-120. | Upon renewal of a disability benefits insurance policy, a carrier may issue this label with updated policy information in lieu of issuing an entire new Form DB-120 poster, as long as the current version of Form DB-120 is already being used. Employers must obtain this form from their insurance carrier. Carriers may contact the Board's Forms Department. |
| DB-125 (2/05) | Employer Identification Card | Employer | Given to employees to provide information to facilitate filing of DB claims. | Issued to employees upon separation from employment. |
| DB-130 (5/02) | Employee's Statement of Exempt Status | Employee | One notarized copy to: NYS Workers' Compensation Board Disability Benefits Bureau 100 Broadway Albany, NY 12241 And One notarized copy to your employer |
Any employee receiving or entitled to receive Social Security retirement benefits may submit this form at any time to waive any and all benefits under the Disability Benefits Law |
| DB-135 (8/03) | Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (No Employee Contribution) | Employer | WCB, Disability Benefits Bureau, Albany | To voluntarily cover employees for whom DB is not required under the Law with no employee contributions to the cost of the coverage. |
| DB-136 (8/03) | Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (Employee Contribution) | Employer | WCB, Disability Benefits Bureau, Albany | To voluntarily cover employees for whom DB is not required under the Law with employee contributions to the cost of the coverage. |
| DB-155 (7/09) | Compliance With Disability Benefits Law | Employers with Board-approved self-insurance for disability benefits | Filed with the government agency issuing a permit, license or contract. The DB-155 must be completed by the Board's Self-Insurance Office. | Upon obtaining a permit, license or contract from a government agency. Board-approved self-insured employers must obtain this form from Board's Self-Insurance Office. (518-402-0247) |
| DB-159.1 (2/03) | Notice of Termination of Employer's Participation in Self-Insured Association, Union or Trustees Plan | Self-Insured Association, Union or Trustees Plan Administrator | One copy to: Workers' Compensation Board, Disability Benefits Bureau, Plans Acceptance Unit, 100 Broadway, Albany, NY 12241; one copy is sent to the employer | When participation in a Board-approved self-insured association, union or trustees plan is terminated. |
| DB-212.3 (1/04) | Notice of Election of a Corporation Which is Required to Have Disability Benefits Coverage for its Employees to Exclude the Sole Shareholder Officer or One of the Two or Both Shareholder Officers of the Corporation from Such Coverage | Sole Shareholder Officer(s) of a Corporation | File with insurance carrier. Board-approved self-insured employers file with WCB Self-Insurance Office. Board-approved group self-insured's file with the WCB Self-Insurance Office and also with your group administrator. | Officers are deemed included in insurance contract until election to exclude is filed. |
| DB-212.5 (11/06) | Notice of Election to Voluntarily Exclude Spouse from Coverage | Employer | File with carrier or, if Board-approved self-insurer (or no carrier and spouse is only employee), with the WCB. | Upon decision to voluntarily exclude spouse from DB coverage. |
| DB-271S (1/11) | Statement of Rights (DBL) | Insurance Carrier/Board-approved self-insurer | Issued by employer to disabled employee. | When covered employee is absent from work due to disability for more than 7 consecutive days, form must be issued within 5 business days thereafter; or within 5 days after employer knows or should know that absence is due to disability, whichever is greater. |
| DB-300 (2/04) | Notice of Proof of Claim for Disability Benefits of Unemployed Claimant | Claimant | Filed with WCB, Disability Benefits Bureau, Albany, if sick or disabled after 4 weeks of unemployment (see DB-450) | File no later than 30 days after becoming sick or disabled. |
| DB-450 (2/04) | Notice and Proof of Claim for Disability Benefits | Employee | File with employer or its insurance company if you become disabled while employed or within 4 weeks after termination. | File no later than 30 days after becoming sick or disabled. Please note: Blank space is available on the reverse of this form for an Employer's Statement (Part C). It is not required by the Workers' Compensation Board, but may be added at the carrier's discretion. |
| Spanish Information Sheet for Form DB-450 (3-07) Guía Para Llenar El Formulario DB-450, Notificación Y Constancia De La Solicitud De Los Beneficios Por Incapacidad |
Esta guía pretende ayudarles a las personas que hablan español como primer idioma a llenar el Formulario DB-450, que se usa con mayor frecuencia para solicitar los beneficios por incapacidad del Estado de Nueva York (por lesiones o enfermedades sufridas fuera del trabajo). Contiene una traducción de las instrucciones y preguntas que deberá responder en el formulario. Si puede, llene la Parte A del Formulario DB-450 en inglés y siga las instrucciones que se brindan a continuación para presentar la solicitud. El proveedor de servicios de salud que le brinde asistencia médica deberá llenar la Parte B ubicada al dorso del formulario antes de que usted lo presente. No presente esta guía junto con la solicitud. | |||
| DB-451 (3/99) | Notice of Total or Partial Rejection of Claim for Disability Benefits | Insurance Carrier/Board-approved self-insurer | Sent to claimant, in triplicate. | Within 45 days of receipt of claim. Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form. |
| DB-455 (3/99) | Notice of Disability Benefits Payment | Insurance Carrier/Board-approved self-insurer | Filed with WCB Disability Benefits Bureau, Albany | Upon making initial payment of disability benefits. |
| DB-470 (11/09) | Preliminary/Final Claim for Reimbursement of Benefits Paid Under DBL | Disability Benefits Insurance Carrier | Workers' Compensation Board, copies to workers' compensation carrier, claimant and his/her representative. | Prior to award of workers' compensation benefits. Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form. |
| DB-791 (2/00) | Tables of Permanent Contributions | Reference table of employee contributions for employer use | Not filed | Not filed |
| DB-802 (4/04) | Employer's Application to Have Association, Union or Trustee Plan Accepted as Employer's Plan | Employer files form after Association, Union or Trustee has signed it. | Disability Benefits Bureau, Plans Acceptance Unit | When an employer becomes a participant in a plan administered by an association, union or trust. |
| DB-820/829 (5/07) | Certificate/Cancellation of Insurance | Carriers insuring employers for disability benefits through Plan Coverage, Enriched Coverage, or Class Coverage. | ONLY insurers providing Plan Coverage, Enriched Coverage, or Class Coverage file this paper form with the Disability Benefits Office at the Workers' Compensation Board to show proof of statutory disability benefits coverage. | Upon writing a disability benefits policy for Plan Coverage, Enriched Coverage, or Class Coverage. |
| DB-820.1 (10/08) | Supplement to Certificate of Insurance | DB Insurance Carrier | NYS Workers' Compensation Board, Disability Benefits Bureau, 100 Broadway, Albany, NY 12241 | Attached to Form DB-820/829 when an employer is providing Disability Benefits that are greater than those provided under the Statute. |
| DB-840 (2/00) | Carrier's Designation of Authorized Representatives | Insurance Carrier | Disability Benefits Bureau | Whenever authorized representatives change or when directed by WCB. |
| DB-850 (3/02) | Application for Acceptance of Insurance Form | Insurance Carrier | Disability Benefits Bureau, Insurance Examining Unit | Whenever a new contract form is submitted for acceptance. |
| DC-120 (1/11) | Discharge or Discrimination Complaint | Employee who is alleging that an employer has discharged or discriminated against him/her because he/she has claimed or attempted to claim compensation. | File two copies of Form DC-120 with: Workers' Comp. Board Discrimination Unit 111 Livingston St. Room 2317 Brooklyn, NY 11201 |
Any complaint alleging an unlawful discriminatory practice must be filed within two years of the commission of such practice. |
| DD-1 (2/06) | Direct Deposit of Benefit Authorization Form | A claimant who is receiving regular, continuing workers' compensation lost wage benefits and wishes to have his/her workers' compensation benefit checks directly deposited into a checking or savings account at a financial institution. | Insurance Carrier or Board-approved self-insured employer. DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD. Please note: current law does not mandate that all carriers offer direct deposit. Check with the carrier before filing. |
Please read all information and instructions on the reverse of the form. |
| DD-2 (9/05) | Biannual Recertification to Entitlement to Benefits | A claimant who is having benefit checks directly deposited in a financial institution. | Insurance Carrier or Board-approved self-insured employer. DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD. |
Every six months, upon receipt of the form from the carrier/Board-approved self-insured employer. |
| DT-1 (3/12) | Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider | Insurance Carrier or Diagnostic Testing Network | Copy to employee and his/her representative, and health provider. | To Claimant when the statement of Claimant's Rights is mailed - within 14 days of C-2 or with first check per WCL 110 OR when the carrier contracts with a DTN To medical provider when carrier contracts with a DTN, or at time of first medical bill. |
| EC-32.1 (9/05) (obsolete) |
Replaced by Form C-32.1 | |||
| Electronic Attachment (5/01) | Attachment to Form_______ (may accompany any Board form.) | All parties may use this form. | Staple to Board form being filed and submit together according to the instructions given on the primary form. | For your convenience, if additional space is needed to complete an item or items on a Board form, you may use this attachment, being sure to fill in all identifying information at the top of the form, and staple it to the form being submitted. |
| FCE-4 (1/11) | Practitioner's Report of Functional Capacity Evaluation | Physical or Occupational Therapist | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | See reverse of form for complete filing indications and requirements. |
| GSI-105.2 (2/02) | Certificate of Participation in Workers' Compensation Group Board-approved self-insurance | Employers participating in group self-insurance for workers' compensation | Filed with the government agency issuing a permit, license or contract. The GSI-105.2 must be completed by the group self-insurance administrator. | Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their group self-insurance administrator. For further information contact the Board's Self-Insurance Office at (518) 402-0247. |
| HIMP-1(1/09) | Health Insurer's Request for Reimbursement | Private Health Insurer/Health Benefits Plan | Insurance carrier or Board-approved self-insurer | When claiming reimbursement for health benefits paid in a workers' compensation case |
| HIPAA-1 (12-03) | Claimant's Authorization to Disclose Health Information (Pursuant to HIPAA) | Claimant | Give the completed form to your doctor, who will keep it with your records. THIS FORM SHOULD NOT BE FILED WITH THE WORKERS' COMPENSATION BOARD. | Click here for Workers' Compensation Guidelines on HIPAA Restrictions and Medical Records |
| HP-1 (4/05) | Health Provider's Request for Decision on Unpaid Medical Bill(s) | Health Provider | Office of Health Provider Administration, 100 Broadway-Menands, Albany, NY 12241 | See detailed instructions and time limits on forms. |
| HP-4 (4/05) | Notice to Chair: Health Provider's and Insurer's Withdrawal of Request for Arbitration | Health Provider or Insurance Carrier/Board-approved self-insurer | Office of Health Provider Administration, 100 Broadway-Menands, Albany, NY 12241 | See reverse of form for filing conditions |
| HP-J1 (7-08) | Provider's Request for Judgment of Award (WCL 54-b) | Authorized Workers' Compensation Health Provider | Workers' Compensation Board Office of Health Provider Administration 100 Broadway - Menands Albany, NY 12241 | For awards/decisions made on or after March 13, 2007. Upon issuance of an administrative award and/or arbitration decision you must wait at least 30 days before requesting consent for judgment. To avoid the complications of filing unnecessary requests, waiting 60 days is recommended. The 60 day time period will allow for carriers' billing/payment cycles. |
| IG-1 (5-08) | Fraud Complaint | Anyone Suspecting Workers' Compensation Related Fraud | Workers' Compensation Board, Fraud Inspector General, 20 Park Street, Albany, NY 12207 | When Fraud is Suspected |
| IG-2 (5-08) | Employer Fraud Referral Form | Anyone suspecting an EMPLOYER is violating workers compensation coverage requirments, such as no coverage, underreporting or concealing information, employer misclassifying employees. | Workers' Compensation Board, Fraud Inspector General, 20 Park Street, Albany, NY 12207 | When Fraud is Suspected |
| IME-3 (1/11) | Practitioner's Report of Request for Information/Response to Request Regarding Independent Medical Examination | Practioners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board | To report request for information - file within 10 days of receipt of the request. To report response to a request for information - file within 10 days of submission of response. See form for complete instructions. |
| IME-4 (1/11) | Practitioner's Report of Independent Medical Examination | Practioners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board; insurance carrier or Board-approved self-insured employer; claimant's attending physician or other attending practitioner; the claimant's representative, if any, and the claimant. | Report shall be filed with the Board and provided to all parties on the same day in the same manner. |
| IME-5 (1/11) | Claimant's Notice of Independent Medical Examination | Health Provider or Insurance Carrier | Mail to the claimant, and Workers' Compensation Board. | Claimant must receive notice by mail at least seven business days prior to the scheduled examination. |
| IME-7 (4/05) | Statement of Registration (Sec. 13n -WCL) | Entities deriving income from independent medical examinations | Office of Health Provider Administration, 100 Broadway-Menands, Albany, NY 12241 | A completed registration form and receipt of a registration number assigned by the Board are required for all IME entities conducting business on or after March 20, 2001. File as soon as possible. Statement must include the notarized signature of an officer of the company, and must be accompanied by a $250 registration fee. |
| MD-1 (1/11) | Attending Doctor's Request for Medical Authorization Determination | Attending Doctor | Workers' Compensation Board | When a carrier or Board-approved self-insured employer has not responded within 30 days to a request for authorization for special services costing more than $1000. SEE INSTRUCTIONS ON FORM FOR NECESSARY FILING CONDITIONS. |
| MD-3 (1/11) | Carrier/Board-approved self-insured employer's Objection to Attending Doctor's Request for Medical Authorization Determination | Carrier/Board-approved self-insured employer | Workers' Compensation Board | Within ten (10) days after filing of Form MD-1, Request for Medical Authorization Determination |
| MG-1 (1/11) | Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response | Health Care Provider | Workers' Compensation Board and Insurance Carrier | Request confirmation from the Insurance Carrier that the procedure or test is based on a correct application of the Medical Treatment Guidelines. |
| MG-1.1 (12/10) | Continuation to Form MG-1, Attending Doctor's Request for Optional Prior Approval | Health Care Provider | Workers' Compensation Board and Insurance Carrier | Request confirmation from the Insurance Carrier that more than one procedure or test is based on a correct application of the Medical Treatment Guidelines. |
| MG-2 (1/11) | Attending Doctor's Request for Approval of Variance and Carrier's Response | Health Care Provider | Workers' Compensation Board, Insurance Carrier, Injured Employee and his/her representative | To request testing or treatment that is outside or exceeds the Medical Treatment Guidelines. |
| MG-2.1 (12/10) | Continuation to Form MG-2, Attending Doctor's Request for Approval of Variance | Health Care Provider | Workers' Compensation Board, Insurance Carrier, Injured Employee and his/her representative | To request more than one test or treatment that is outside or exceeds the Medical Treatment Guidelines. |
| MR/IME-1 (4/05) | Health Provider's Application for Authorization Under the Workers' Compensation Law | Health Providers | See instructions on form | When seeking authorization to render care under the Workers' Compensation Law, or to conduct Independent Medical Examinations under the Workers' Compensation Law, or both. |
| MR-4 (1/11) | Impartial Specialist's Report of Medical Records Review | Impartial Specialist | Workers' Compensation Board | When the Board has requested an Impartial Specialist Medical Records review on procedures that require pre-authorization under Medical Treatment Guidelines. |
| OC-110A (1/11) | Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) | Claimant | Workers' Compensation Board | Claimant must submit form with original signature in order to allow release of his/her records to parties not otherwise authorized to receive them. |
| OC-110AS (1/11) | AUTORIZACIÓN DE RECLAMANTE PARA PERMITIR ACCESO A EXPEDIENTES ANTE LA JUNTA | Reclamante | Radicado en Oficina Distrito WCB | Reclamante deberá someter forma firmada en su original para autorizar acceso a su expediente a personas o entidades usualmente no autorizadas para recibirlos. |
| OC-110AORD (7-10) | Request for Judicial Order – Access to Case Files | Individuals or Entities not considered parties in interest who are seeking access to case files | Workers' Compensation Board | As needed. This form may be submitted in person at any Board office, mailed or faxed (877-533-0337) to the Board. |
| OC-400 (1/11) | Notice of Retainer and Substitution | Attorney/ Licensed Representative | Workers' Compensation Board, copy to all claimant's health providers, copy to insurance carrier/self-insured employer. | Immediately upon being retained. |
| OC-400.1 (1/11) | Attorney/ Representative's Application for Fee | Attorney/ Licensed Representative | Workers' Compensation Board, copy to claimant. | When fee of more than $450 is requested. If claimant not present, he/she must be advised of fee request, using this form, 10 days prior to awarding of fee. |
| OC-400.5 (3/09) | Attorney/ Representative's Certification of Form C-3 or C-7 | Attorney/ Licensed Representative | Workers' Compensation Board, copy to all other parties of interest. | Claimant's Attorney/Representative: Within 5 days after you have been retained by a claimant who has previously filed Form C-3 without your certification. Carrier's Attorney/Representative: If Form C-7 has been filed without your written certification, OC-400.5 must be filed before you may appear on behalf of the carrier. |
| OC-401.1R (2/12) | Renewal Application for License to Appear on Behalf of Claimant | This form is to be completed by the individual renewing license. | Workers' Compensation Board, Licensing Bureau | License Renewal |
| OC-403.1 (2/12) | Initial Application to become a NYS Licensed TPA | This form is to be completed by two senior officers of the corporation and the qualifying officer. | Workers' Compensation Board, Licensing Bureau | New Licenses |
| OC-403.1R (2/12) | Renewal Application for TPA License | This form is to be completed by two senior officers of the corporation and the qualifying officer. | Workers' Compensation Board, Licensing Bureau | License Renewal |
| OC-403.2 (2/12) | Initial Application by Employee of Licensee | This form is to be completed by the qualifying officer. | Workers' Compensation Board, Licensing Bureau | New Licenses |
| OC-403.2R (2/12) | Renewal Application by Employee of Licensee | This form is to be completed by the qualifying officer. | Workers' Compensation Board, Licensing Bureau | License Renewal |
| OC-403.3 (2/12) | Stockholder of Corporation Applying for License (New and Renewal) | This form is to be completed by each principal stockholder owning at least 20 percent of the corporation's stock. | Workers' Compensation Board, Licensing Bureau | New Licenses and License Renewal |
| OC-406 (5/08) | Notice of Retainer and Appearance on Behalf of Employer | Attorney representing employer before the Board in a no insurance, discrimination or double indemnity case. | Workers' Compensation Board | Immediately upon being retained. |
| OC-407 (3/97) | Self-Insurer’s Representative’s Bond | Third Party Administrators | Workers’ Compensation Board, Licensing Bureau | At time of initial application or renewal |
| OC-409 (2/12) | Initial Application to take License Representative Exam | This form is to be completed by individual taking exam. | Workers' Compensation Board, Licensing Bureau | Must be postmarked no later than three weeks prior to examination. |
| OC-923 (1/11) | Important Information for Employers Operating in New York State | General DB and WC information made available to the public | Not filed | Not filed |
| OT/PT-4 (1/11) Paper Version 
[OT/PT-4 On-lineSubmission] |
Occupational/ Physical Therapist's Report | Occupational/ Physical Therapist | Workers' Compensation Board, insurance carrier, referring doctor, injured employee or his/her representative. | 48 hour initial report, within 48 hours of first treatment. 15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
| PH-16.2 (2/11) Paper Version [PH-16.2 On-line Submission] Adobe Format Overview/Features |
Pre-Hearing Conference Statement | Claimant's Attorney or Licensed Representative; Carrier or Board-approved self-insured employer | Workers' Compensation Board, with copies served on all other parties of interest. | Ten days before scheduled pre-hearing conference for controverted (C-7) cases. |
| PS-4 (1/11) | Psychologist's Report | Psychologist | Workers' Compensation Board, insurance carrier, injured employee or his/her representative. | 48 hour initial report, within 48 hours of first treatment. 15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
| R (8/05) | Carrier's Report on Rehabilitation | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to claimant and his/her representative. | Within 30 days after the earlier of the following: -Date lost time (intermittent or continuous) exceeds 12 weeks. -Date rehabilitation services instituted or arranged. |
| RB-89 (1/11) | Cover Sheet - Application for Board Review | Party applying for Board Review of WC Law Judge decision | Workers' Compensation Board, copy to all other parties of interest. | Within 30 days after notice of filing of the decision of the WC Law Judge. |
| RB-89.1 (1/11) | Cover Sheet - Rebuttal of Application for Board Review | Party rebutting application for Board Review of WC Law Judge decision | Workers' Compensation Board, copy to all other parties of interest. | Within 30 days after service of the application for review upon the party making the rebuttal. |
| RB-89.2 (1/11) | Cover Sheet – Application for Reconsideration / Full Board Review | Party applying for Full Board Review of Board Panel decision. | Workers' Compensation Board, copy to all other parties of interest. | Within 30 days after notice of filing the decision of the Board Panel. . |
| RB-89.3 (1/11) | Cover Sheet – Rebuttal of Application for Reconsideration / Full Board Review | Party rebutting application for Full Board review of Board Panel decision | Workers' Compensation Board, copy to all other parties of interest | Within 30 days after service of the application for Full Board Review upon the party making the rebuttal. |
| RFA-1W (1/11) Paper Version [RFA-1W On-line Submission] |
Request for Assistance by Injured Worker | Claimant | Workers' Compensation Board | The form may be filed at any time after the Board assigns a WCB case number, or any time after the Board has indicated that no further action (NFA) will be taken. REPLACES FORM RFA-1 |
| RFA-1LC (5/11) Paper Version [RFA-1LC On-line Submission] |
Request for Further Action by Legal Counsel | Claimant's Representative | Workers' Compensation Board, with copy to employer's insurance carrier or directly to employer or third party administrator if employer is a Board-approved self-insurer. | The form may be filed at any time after the assembly or indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORM RFA-1. |
| RFA-2 (5/11) Paper Version [RFA-2 On-line Submission] |
Request for Further Action by Carrier/Employer | Insurance Carrier or Board-approved self-insured employer | Workers' Compensation Board, with copies to claimant and his/her representative, if any. | The form may be filed at any time after the assembly or indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. |
| SI-12 (5/09) | Affidavit Certifying That Compensation Has Been Secured | Employers with Board-approved self-insurance for workers' compensation | Filed with the government agency issuing a permit, license or contract. The SI-12 must be completed by the Board's Self-Insurance Office and approved by the Board's Secretary. | Upon obtaining a permit, license or contract from a government agency. Board-approved self-insurers must obtain this form from Board's Self-Insurance Office. (518) 402-0247 |
| U-26.3 | NY State Insurance Fund Certificate of Workers' Compensation Coverage (This is the State Insurance Fund's equivalent of Workers' Compensation Board Form C-105.2) | Employers insured for workers' compensation through the State Insurance Fund | Filed with the government agency issuing a permit, license or contract. | Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from the State Insurance Fund. |
| VAW-1 (8/97) | Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death | Volunteer Ambulance Worker | Send to political subdivision liable for benefits. [This is not a claim for benefits. See VAW-3] | Within 90 days after date of injury or death (unless claim form VAW-3 or VAW-62 is filed within that period). |
| VAW-2 (1/11) Paper Version [VAW-2 On-line Submission] |
Political Subdivision's Report of Injury to Volunteer Ambulance Worker | Political Subdivision | Workers' Compensation Board | Within 10 days after injury is incurred. |
| VAW-3 (1/11) | Volunteer Ambulance Worker's Claim for Benefits | Volunteer Ambulance Worker | Workers' Compensation Board, and political subdivision liable for benefits. [If filed within 90 days of injury, it is not necessary to file VAW-1.] | Within 2 years after injury is incurred. |
| VAW-62 (1/11) | Claim for Volunteer Ambulance Workers' Benefits in a Death Case | Claimant | Workers' Compensation Board and designated officer (see detailed instructions on form) | Within two years after death (but see also Form VAW-1) |
| VAW-105 (1/11) | Notice of Compliance - Volunteer Ambulance Workers' Law | Political Subdivision or Unaffiliated Volunteer Ambulance Service insured for Volunteer Ambulance Workers' Benefits through an insurance carrier or Board-approved self-insurance. | This form is not filed. It must be completed by the insurance carrier or self-insured political subdivision or unaffiliated ambulance service with identifying insurance information and then displayed in the ambulance company headquarters. | Upon securing of volunteer ambulance workers' insurance or self-insurance. Political subdivisions or unaffiliated ambulance services must obtain this form from their insurance carrier or group self-insurance administrator. Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
| VAW-501 (1-06) Benefit rates for all dates of death |
Volunteer Ambulance Workers' Benefit Rates – Death Benefits | Benefit rates for dates of death between: | ||
| VDF-1 (1/12)
[VDF-1 On-line Submission] |
Loss of Wage Earning Capacity Vocational Data Form | Claimant | Workers' Compensation Board, copy to insurance carrier | Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim. |
| VF-1 (8/97) | Notice to Political Subdivision of Volunteer Firefighter's Injury or Death | Volunteer Firefighter | Send to political subdivision liable for benefits. [This is not a claim for benefits. See VF-3] | Within 90 days after date of injury or death (unless claim form VF-3 or VF-62 is filed within that period) |
| VF-2 (1/11) Paper Version [VF-2 On-line Submission] |
Political Subdivision's Report of Injury to Volunteer Firefighter | Political Subdivision | Workers' Compensation Board | Within 10 days after injury is incurred. |
| VF-3 (1/11) | Volunteer Firefighter's Claim for Benefits | Volunteer Firefighter | Workers' Compensation Board, and political subdivision liable for benefits. [If filed within 90 days of injury, it is not necessary to file VF-1.] | Within 2 years after injury is incurred. |
| VF-62 (1/11) | Claim for Volunteer Firefighter Benefits in a Death Case | Claimant | Workers' Compensation Board and designated officer (see detailed instructions on form) | Within two years after death (but see also Form VF-1) |
| VF-105 (1/11) | Notice of Compliance - Volunteer Firefighters Benefit Law | Political Subdivision insured for Volunteer Firefighters' Benefits through an insurance carrier or Board-approved self-insurance. | This form is not filed. It must be completed by the insurance carrier or self-insured political subdivision with identifying insurance information and then displayed in the firehouse and fire company headquarters. | Upon securing of volunteer firefighters' insurance or self-insurance. Political subdivisions must obtain this form from their insurance carrier or group self-insurance administrator. Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
| VF-501 (10-06) Benefit rates for all dates of death |
Volunteer Firefighters' Benefit Rates – Death Benefits | Benefit rates for dates of death between:
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| VF/VAW-10 (10-06) | Carrier's Request for Benefit Increase Reimbursement Under Sec. 51 VFBL/VAWBL | Insurance Carrier/Self-Insurer | Forward original and one copy, along with any required documentation to: Workers' Compensation Board, Fund for Reopened Cases Unit Room 312 20 Park Street Albany, NY 12207 |
Claims for reimbursement should be submitted for 52 week periods, beginning one year from the date of the first payment, and annually thereafter while payments continue. |
| VF/VAW-11C (1/11) |
Volunteer's Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV Per VFBL/VAWBL Section 11-c(1) | Volunteer Firefighter or Volunteer Ambulance Worker | Executive Officer of Fire Company or Ambulance Company, copy to the Workers' Compensation Board | Following significant risk of transmission of HIV incurred in the line of duty as a volunteer firefighter or ambulance worker. Executive Officer must authorize appropriate medical examination within 8 hours of receipt of Form VF/VAW-11C. Contact the nearest office of the Workers' Compensation Board if authorization is not granted within that time. THIS FORM IS NOT A NOTICE OF INJURY/OCCUPATIONAL DISEASE OR A CLAIM FOR BENEFITS UNDER THE VFBL OR VAWBL. (See Forms VF-1, VAW-1, VF-3 and VAW-3) |
| WC/DB-100 (9/07) (obsolete) |
See Form CE-200 | |||
| WC/DB-101 (7/04) (obsolete) |
See Form CE-200 | |||
| WTC-12 (1/11) | Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL §162 | Employees or volunteers who participated in World Trade Center rescue, recovery and clean-up operations between 9-11-01 and 9-12-02. | Workers' Compensation Board | Not later than September 11, 2010 |
| WTC-16 (7/07) | Cover Sheet: List of Itemized Medical Bills for Temporary Payment by the World Trade Center Volunteer Fund in Controverted World Trade Center Case | Insurance Carrier or Board-approved Self-Insurer | Workers' Compensation Board | Initially within 15 days and monthly thereafter |
| WTCVol-3 (2/04) | World Trade Center Volunteer's Claim for Compensation | Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Staten Island Landfill on or after 9-11-01 | NYS Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 | Within two years of injury/illness or within two years after volunteer knew or should have known that injury or illness was related to volunteer service. |
| W-32R (3/11) | WAMO Settlement Agreement-Section 32 | Parties of Interest | To obtain WAMO signature, mail to: Waiver Agreement Management Office (WAMO) NYS Workers' Compensation Board 20 Park Street - Room 208 Albany, NY 12207 When all POIs have signed, mail to the WCB District Office. |
Special Disability Funds must have all or partial liability. May be filed at any time during an open and pending case, and may cover any and all issues. |
If the form you are looking for is not listed above, or in the list of Common Board Forms, please e-mail the Board's Forms Department.
View a list of all prescribed Workers' Compensation Board forms 
