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Important Update on Workers' Compensation Board Operations (June 2021)

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Workers’ Compensation Board Common Forms

Forms

Completing Forms

If you require assistance with completing these forms, please contact us.

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it. If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. If you still have trouble with the form, please email the Board's Forms Department.

Multi-page Forms
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.

Certificates of Insurance
Forms C-105, C-105.1, C-105.2, DB-120, DB-120.1 and DB-155 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. Self-insured employers can contact the Office of Self-Insurance at selfinsurance@wcb.ny.gov for the Certificate of Self-Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law (Form DB-155).

C-4 Medical Billing Forms
It is anticipated that all versions of the C-4 medical billing forms (except the C-4.3) will be replaced by the required XML submission of the CMS-1500 form on or about July 1, 2021. Information on the CMS-1500 Initiative

Original Signature Requirement

COVID-19 Response: Original Signature Requirement Relief – March 2020

While the Workers' Compensation Board does not normally accept a claimant's electronic signature on Board-prescribed forms, the original signature requirement has been relieved for the duration of the COVID-19 emergency for the forms specifically listed in the Board's announcement: Emergency Relief from Original Signature Requirements on Listed Documents.

The Board, as standard practice, does not accept electronic signatures on Board-prescribed forms, as the Board is unable to efficiently evaluate the electronic signature process used by an insurer, health care provider, attorney, or licensed representative to ensure that the procedure complies with the New York Electronic Signatures and Records Act (ESRA) and applicable regulations. Therefore, a claimant's ink signature must be supplied when a claimant's signature is required by law.


Common Workers' Compensation Board Forms

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 (6-16) 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.
C-2F (1/14) Paper Version

[C-2F Instructions]
Employer's Report of Work-Related Injury/Illness Employer (contact your insurance carrier who can provide advice for the best method to report the information.) Workers' Compensation Board, copy to insurance carrier. Within ten days after occurrence of Injury/Illness.
CLAIMANT INFORMATION PACKET

Compendio Información Reclamante (Claimant Information Packet, Spanish)
CLAIMANT INFORMATION PACKET 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.
C-3 (4/19) Paper Version

[C-3 Online 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-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 (8/20)
Paper Version


[C-4 Online
Submission
]


See Subject No. 046-398 — Authorized Provider Shortage in Rochester Area; Temporary Change in Medical Reporting Requirements

Information on the CMS-1500 Initiative
Doctor's Initial Report
  • Physician
  • Nurse Practitioner
  • Podiatrist
  • Chiropractor
  • Licensed Clinical Social Worker
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)

Information on the CMS-1500 Initiative
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 Care 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 (10/15)
Paper Version


[C-4.2 Online
Submission
]


Information on the CMS-1500 Initiative
Doctor's Progress Report
  • Physician
  • Nurse Practitioner
  • Physician Assistant
  • Podiatrist
  • Chiropractor
  • Licensed Clinical Social Worker
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 (5/18)
Paper Version


[C-4.3 Online
Submission
]


Implementation of Forms Associated with SLU Evaluations
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 of MMI and/or permanent impairment.
C-4 AMR (10/15)
Paper Version


[EC-4 AMR Online
Submission
]


Information on the CMS-1500 Initiative
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 (7-18)

Search for Insurer Contacts

COVID-19 Update

Earlier versions of this form are no longer accepted and if received no action will be taken by the Board.
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 representative. If 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 (10/15) Online
Submission


Information on the CMS-1500 Initiative
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 (10/15) 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-8.1 (8/18) Paper Version

WCB COVID-19 Guidance: Attaching Medical Bills to Form C-8.1B

See Subject No. 046-1362R — Important Updates Regarding Forms C-8.1 and C-8.4

[C-8.1 Online 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)

See Subject No. 046-1362R — Important Updates Regarding Forms C-8.1 and C-8.4
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 (6/17) Paper Version


[C-11 Online 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-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 (4/19) 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 (4/21) Waiver Agreement - Section 32 WCL 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 (2/16)

Video: Settling Your Claim
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, Section 32 Agreement.
C-32E (7/19) Section 32 - Electronic Signature Insurance Carrier, Self-Insured Employer or Third-Party Administrator Workers' Compensation Board Filed as an attachment to the C-32 agreement.
C-32-I (6/20) Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement 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-35 (4-17) Extreme Hardship Redetermination Request Section 35(3) of the Workers' Compensation Law Injured Worker Workers' Compensation Board When an injured worker is requesting a redetermination due to an extreme hardship as described in Section 35(3) of the Workers' Compensation Law and has been classified with a permanent partial disability with a loss of wage earning capacity of greater than 75% and capped benefits will expire within one year.
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 (6/16) 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-105 (9/17) 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 or self-insured administrator 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.
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 (9/17) 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
328 State Street Schenectady, NY 12305-2318
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-105.31 (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,
328 State Street Schenectady, NY 12305-2318, 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,
328 State Street Schenectady, NY 12305-2318.
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,
328 State Street Schenectady, NY 12305-2318.
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,
328 State Street Schenectady, NY 12305-2318.
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 (6/17) Paper Version


[C-240 Online Submission]
Employer's Statement of Wage Earnings Preceding Date of Accident Employer Workers' Compensation Board Within 10 days of request by the Board.
C-251 (10/20)
(MS Excel)
Carrier’s Request Reimbursement of Indemnity Payments Under WCL Section 14(6) or Section 15(8) Insurance Carrier/Board-approved self-insurer Email completed form to: SpecialFunds@wcb.ny.gov For twenty-six week periods, per form instructions.
C-251.1 (01/21) Carrier’s Request for Reimbursement of Medical Payments Under WCL Section 15(8) Insurance Carrier/Board-approved self-insurer Email completed form to: SpecialFunds@wcb.ny.gov or Mail completed form to: NYS Workers’ Compensation Board Attention: Special Funds Group 328 State Street, Room 331 Schenectady, NY 12305 For twenty-six week periods, per form instructions.
C-251.4 (10/20)
(MS Excel)
Insurer's Request For Reimbursement Of Indemnity Payments Under WCL §25-a(9) Insurance Carrier/Board-approved self-insurer Email completed form to: SpecialFunds@wcb.ny.gov
C-251.6 (01/21) Carrier’s Request for Reconsideration of Reduction Under WCL Section 14(6) or Section 15(8) Insurance Carrier/Board-approved self-insurer Email completed form to: SpecialFunds@wcb.ny.gov
C-251N (01/21) Carrier’s Notification of Initial Request for Reimbursement Under Section 14(6) or Section 15(8) Insurance Carrier/Board-approved self-insurer Email completed form to: SpecialFunds@wcb.ny.gov
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 (5/19) Claimant's Record of Job Search Efforts/Contacts Claimants who are partially disabled and are not employed or working, except a claimant who was entitled to benefits at the time he/she was classified with a permanent partial disability. This form and all documents supporting your job search efforts must be submitted to the Board in advance of your hearing, or brought with you on the date of your hearing and will be collected by the WC Law Judge. Please refer to the detailed instructions on page two of this form for where/when to file this form. This form is used to record efforts made to search for work within the claimant's medical restrictions and with the assistance of an agency or employment counselor.

Please refer to the detailed instructions on page two of this form for where/when to file this form.
C-258.1 (7/17) Claimant's Record of Independent Job Search Efforts Claimants who are partially disabled and are not employed or working, except a claimant who was entitled to benefits at the time he/she was classified with a permanent partial disability. This form and all documents supporting your job search efforts must be submitted to the Board in advance of your hearing, or brought with you on the date of your hearing and will be collected by the WC Law Judge. Please refer to the detailed instructions on page two of this form for where/when to file this form. This form is used to record efforts made to search for work within the claimant's physical restrictions through an independent job search.

Please refer to the detailed instructions on page two of this form for where/when to file this form.
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 (10/16) 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 (9/16) Statement of Rights (WCL) Insurance Carrier/Board-approved self-insurer Sent to injured employee. Within 14 days of receipt of initiating FROI, or with initial benefit check, whichever is earlier.
C-500 (7-19) Disability Benefits, Rates and Awards Maximum and Minimum Award Rates From 7/1/58 to Present
C-500.1 (6-16) Death Benefits, Rates and Awards Use Form C-500.1 to determine death benefits in claims filed under the Workers’ Compensation Law, the Volunteer Firefighter Benefits Law, and the Volunteer Ambulance Worker Benefits Law.
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.
   
CE-200 (12/08) 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)
DB-26 (10/17) Notice of Election of Political Subdivision for Self-Insurance-Disability and Paid Family Leave Benefits Law Political subdivision, ambulance or fire district Notice to the Chair that a political subdivision, ambulance or fire district has elected to secure Disability and/or Paid Family Leave benefits as a self-insurer When appropriate
DB-118 (10/17) Employer's Statement for the Purpose of Terminating Status as a Covered Employer Employer Mail to Workers' Compensation Board, Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200 When terminating status as a covered employer.
DB-120 (11/17) Notice of Compliance – New York State Disability Benefits 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 (10/17) Certificate of Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law Employers 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-120.2 (10/17) Certificate of Participation in Disability or Disability and Paid Family Leave Benefits Group Self-Insurance Employers Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The DB-120.2 must be completed by the Plan Administrator or authorized representative. Employers must obtain this form from their administrator. The administrator should contact Certificates@wcb.ny.gov to get a copy of the form they can distribute to their members.
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 (5/19) Employer Identification Information, Disability Benefits Law Employer Given to employees to provide information to facilitate filing of DB claims. Issued to employees upon separation from employment.
DB-130 (5/19) Employee's Statement of Exempt Status Employee One notarized copy to:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029

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 and Paid Family Leave Benefits Law
DB-135 (09/19) Employer’s Application for Voluntary Coverage (No Employee Contribution) Employer Workers' Compensation Board, Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200 or email to PAU@wcb.ny.gov 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 (09/19) Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (Employee Contribution) Employer Workers' Compensation Board, Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200 or PAU@wcb.ny.gov To voluntarily cover employees for whom DB is not required under the Law with employee contributions to the cost of the coverage.
DB-150 (07/17) Application for Self-Insurance-Disability and Paid Family Leave Benefits Employer Filed when applying for self-insurance under the Disability and Paid Family Leave Benefits Law No filing deadline
DB-155 (9/16) Certificate of Self-Insurance Coverage under the NYS Disability and Paid Family Leave 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 the Board's Self-Insurance Office by emailing selfinsurance@wcb.ny.gov
DB-212.3 (10/17) Notice of Election of a Corporation which is required to have Disability and Paid Family Leave Benefits Coverage for its Employees under the Disability and Paid Family Leave Law to Exclude the Sole Shareholder-Officer or One of Two Shareholder-Officers or 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 (10/17) Notice of Election to Voluntarily Exclude Spouse from Coverage Pursuant to Section 212, Subdivision 5 of the NYS Disability and Paid Family Leave Benefits Law Employer File with Insurance carrier or, if Board-approved self-insurer (or no carrier and spouse is only employee), with the WCB. File when election is made to exclude spouse from coverage.
DB-271S (5/19) 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-450 (1/20) Notice and Proof of Claim for Disability Benefits Claimant If you became sick or disabled while employed or you became sick or disabled within four (4) weeks after termination of employment, file with your employer or its insurance carrier.

If you became sick or disabled after having been unemployed for more than four (4) weeks, file with:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
File no later than 30 days after becoming sick or disabled.
DB-450.1 (9-17) Claimant's Statement Regarding No Fault or Personal Injury Claimant Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
File with Form DB-450.
DB-451 (5/19) 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-470 (1/17) 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-802 (10/17) Application to have Association, Union or Trustees Plan Accepted/Terminated as Employer's Plan Employer files form after Association, Union or Trustee has signed it. Email to PAU@wcb.ny.gov or mail to Workers' Compensation Board, Plans Acceptance Unit, P. O. Box 5200, Binghamton, NY 13902-5200 When an employer becomes a participant in a plan administered by an association, union or trust.
DB-800 (11/19) Self-Insured Employers providing Disability and/or Paid Family Leave Benefits offering a shorter waiting period or a longer duration than statute requires (Application and Agreement) Self-Insured Employers providing Disability and/or Paid Family Leave Benefits offering a shorter waiting period or a longer duration than statute requires Email to PAU@wcb.ny.gov or mail to Workers’ Compensation Board, Plans Acceptance Unit, P.O. Box 5200, Binghamton, NY 13902-5200 When a Self-Insured Employer wants to provide Disability and/or Paid Family Leave Benefits to a Class of employees and/or offers a shorter waiting period, or a longer duration than statue requires.
DB-801 (11/19) Plan of an Association of Employers or Employees, Union or Trustees Providing Disability and/ or Paid Family Leave Benefits (Application and Agreement) Plan Administrator for Association of Employers or Employees, Union of Trustees files. Email to PAU@wcb.ny.gov or mail to Workers’ Compensation Board, Plans Acceptance Unit, P.O. Box 5200, Binghamton, NY 13902-5200 When an Association of Employers or Employees, Union or Trustees wants to become a Plan that provides Disability and/or Paid Family Leave Benefits.
DB-820/829 (9/17) Certificate/Cancellation of Insurance Carriers insuring employers for disability and paid family leave 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 and paid family leave benefits coverage. Upon writing a disability and paid family leave benefits policy for Plan Coverage, Enriched Coverage, or Class Coverage. Carriers may contact the Board's Forms Department to obtain this form.
DB-820.1 (3/18) Supplement to Certificate of Insurance Carriers insuring employers for disability and paid family leave benefits through Plan Coverage, Enriched Coverage, or Class Coverage File with Form DB-820/829. Attach to and make part of Form DB-820/829.
DB-820.3 (10/17) Certificate of Insurance on behalf of Association, Union or Trustees of Plan benefits. Carriers insuring employers for Disability and Paid Family Leave benefits through Plan Coverage. Carriers are to submit this form to the Board on behalf of the Association, Union or Trust. The form requires a signature from the insurance carrier and an authorized representative from the Association, Union or Trust. Must be filed with the DB-801 initial application. Upon writing a Disability and Paid Family Leave benefits policy for Plan Coverage. Carriers may contact the Board's Forms Department to obtain this form.
DB-829.3 (10/17) Notice of Cancellation for Association, Union or Trustees of Plan benefits. Carriers insuring employers for Disability and Paid Family Leave benefits through Plan Coverage. Carriers are to submit this form to the Board on behalf of the Association, Union or Trust. The form requires a signature from the insurance carrier and an authorized representative from the Association, Union or Trust. Carriers may contact the Board's Forms Department to obtain this form.
DB-850 (10/17) Application for Acceptance of Insurance Form Under Section 360.1(b)(1) NYCRR Insurance Carrier Email to PAU@wcb.ny.gov or mail to Workers' Compensation Board, Plans Acceptance Unit, P. O. Box 5200, Binghamton, NY 13902-5200 File when new forms needs approval.
DC-120 (7/17) 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 in duplicate:
Workers' Compensation Board
Discrimination Unit
Riverview Center - 150 Broadway
Menands, NY 12204
Any complaint alleging an unlawful discriminatory practice must be filed within two years of the commission of such practice.
DD-1 (5/21) Direct Deposit Authorization Sample Form To begin, change or cancel the transmittal of workers' compensation benefit checks and/or proceeds from a settlement agreement pursuant to WCL § 32 directly to a financial institution. This is a sample form only. Claimant should fill out the form on their insurer or administrator's website and submit the form directly to them. Insurance Carrier or Board-approved self-insured employer.
DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD.
Please read all information and instructions on the front 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 or Diagnostic Testing Network (DTN) can use DT-1 form or a substantially equivalent form to identify one or more DTNs 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 receipt of initiating FROI, 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.
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.
HIMP-1 (7/18) New York State Workers’ Compensation Board Health Insurance Matching Program 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.
HP-1 (2/20) Health Provider's Request for Decision on Unpaid Medical Bill(s) Health Provider REQUEST FOR ADMINISTRATIVE AWARD
NYS Workers' Compensation Board PO Box 5205 Binghamton, NY 13902-5205

REQUEST FOR ARBITRATION
NYS Workers' Compensation Board, Medical Director's Office Riverview Center, Suite 195, 150 Broadway Menands, NY 12204
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 Medical Director's Office, Riverview Center, 150 Broadway – Suite 195, Menands, NY 12204 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 Disputed Medical Bills Unit, 328 State Street, Schenectady, NY 12305 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.
IME-3 (7/14) Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination Independent Examiners 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 (5/18)

Implementation of Forms Associated with SLU Evaluations
Independent Examiner's Report of Independent Medical Examination Independent Examiners 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-4.3A (5/18)

Implementation of Forms Associated with SLU Evaluations
Attachment for Report of Independent Medical Examination Scheduled Loss of Use Independent Examiners 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. File this form as an attachment to Independent Examiner's Report of Independent Medical Examination, IME-4, for Scheduled Loss of Use.
IME-4.3B (5/18)

Implementation of Forms Associated with SLU Evaluations
Attachment for Report of Independent Medical Examination Non-Scheduled Permanent Partial Disability Independent Examiners 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. File this form as an attachment to Independent Examiner's Report of Independent Medical Examination, IME-4, for Non-Scheduled Permanent Partial Disability.
IME-5 (5/18)

Implementation of Forms Associated with SLU Evaluations
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 (4/20) Statement of Registration (Sec. 13n -WCL) Entities deriving income from independent medical examinations Medical Director's Office, Riverview Center, 150 Broadway – Suite 195, Menands, NY 12204 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.
IS-1 (2-13) Physician's Application for Designation as an Impartial Specialist Physician seeking Impartial Specialist designation Workers' Compensation Board, Medical Director's Office When applying for designation as an Impartial Specialist
IS-1R (2-13) Physician’s Application for Renewal of Designation as an Impartial Specialist Physician seeking renewal of Impartial Specialist designation Workers' Compensation Board, Medical Director's Office 60 days prior to the end of your designation term.
IS-4 (2-13) Physician’s Report of Impartial Specialist Examination or Impartial Specialist Record Review Physician Workers' Compensation Board Within 20 days of the examination or within 25 days of receipt of records.
LAC-1 (11-18) Language Access Comment Form Form is for both internal and external use. Workers' Compensation Board New York State’s policy is to provide language access to public services and programs. If you feel that we have not provided you with adequate interpretation services or have denied you an available translated document, please ask for our complaint form to give us your feedback.
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 (4-18)

Search for Insurer Contacts

COVID-19 Update

Earlier versions of this form are no longer accepted and if received no action will be taken by the Board.
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 (4-18)

Earlier versions of this form are no longer accepted and if received no action will be taken by the Board.
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 (4-18)

Search for Insurer Contacts

COVID-19 Update

Earlier versions of this form are no longer accepted and if received no action will be taken by the Board.
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 (4-18)

Earlier versions of this form are no longer accepted and if received no action will be taken by the Board.
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 (8/18) 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 (12/17) 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-110AORD (4-18) 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 (7/19) 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.
An R number is required.
Request R Number
OC-400.1 (8/17) Application for a Fee by Claimant’s Attorney or Licensed Representative Attorney/Licensed Representative Workers’ Compensation Board, copy to the claimant. When fee of more than $1,000 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 (6-13) Attorney/Representative's Certification of Form C-3 or Notice of Controversy 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 Notice of Controversy has been filed without your written certification, OC-400.5 must be filed before you may appear on behalf of the carrier.
OC-400.17 (8/20) Attorney/Licensed Representative Request to Withdraw from Representation Attorney/Licensed Representative Workers' Compensation Board, copy to all other parties of interest. Once completed, this form is to be filed immediately.
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 (10/19) Application for License to Appear on Behalf of, or Represent, Insurers and/or Self-Insurers This form is to be completed by the qualifying officer of the Third-Party Administrator. Workers’ Compensation Board, Licensing Bureau New Application, Renewal Application, or New Qualifying Officer
OC-406 (1/18) 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-408 (10/16) Licensed Representative’s Full Disclosure of Conflict of Interest to Client Licensed Representatives of claimants, employers and carriers Workers’ Compensation Board and the client(s) of the licensed representative. Whenever the licensed representative has an adverse interest or relationship with any of the parties to a proceeding.
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.
OT/PT-4 (7/20)
Paper Version

[OT/PT-4 Online
Submission
]


Information on the CMS-1500 Initiative
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.
PFL-820.1 (3/18) Supplement to Certificate of Insurance Carriers insuring employers for disability and paid family leave benefits through Plan Coverage, Enriched Coverage, or Class Coverage File with Form DB-820/829. Attach to and make part of Form DB-820/829.
PH-16.2 (10/18) Paper Version


[PH-16.2 Online 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 (10/15)

Information on the CMS-1500 Initiative
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 (11/18)

Guidance Document on the Proper Application of Board Rule 300.13

Supplement: Decisional Examples
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 (11/18)

Guidance Document on the Proper Application of Board Rule 300.13

Supplement: Decisional Examples
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 (11/18)

Guidance Document on the Proper Application of Board Rule 300.13

Supplement: Decisional Examples
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 (11/18)

Guidance Document on the Proper Application of Board Rule 300.13

Supplement: Decisional Examples
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 (4/17) Paper Version


[RFA-1W Online 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 (4/17) Paper Version


[RFA-1LC Online 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 (10/16) Paper Version


[RFA-2 Online 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-1 (07/10) Application for Self-Insurance Employers Filed by an applicant for self-insurance under the WCL When appropriate
SI-12 (5/09) Certificate of NYS Workers' Compensation Self-Insurance Coverage 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-insured employers must obtain this form from the Board's Self-Insurance Office by emailing selfinsurance@wcb.ny.gov
SI-26 (11/16) Notice of Election by a Political Subdivision, Ambulance or Fire District (for Self-Insurance) Political subdivision, ambulance or fire district Notice to the Chair that a political subdivision, ambulance or fire district has elected to secure compensation as a self-insurer When appropriate
SI-105.2P (2/13) Certificate of Participation in Workers' Compensation County Self-Insurance Plan Employers participating in county self-insurance plans for workers' compensation Filed with the government agency issuing a permit, license or contract. The SI-105.2P must be completed by the county self-insurance administrator. Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their county self-insurance administrator. For further information contact the Board's Self-Insurance Office at (518) 402-0247
SIG-105.2 (1/12) 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 SIG-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.
SP-Affirmation (12/19) Supervising Physician Affirmation Physician Assistant Workers' Compensation Board Attached to Initial Request for Authorization and whenever a new supervising physician is reported to the Board.
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-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 (9/16) 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.
VBR-1 (3/16) Application for Voluntary Binding Review Represented Claimants, Attorneys, Self-Insured Employers, Carriers, Third-Party Administrators or Special Funds Filed with the Board by E-fax ((518) 402-7115), Email (vbrform@wcb.ny.gov) or Web Upload Any time after the filing of a decision by a WCLJ and prior to the filing of a Memorandum of Understanding by a Board Panel, on appeal, resolving the issues addressed in the WCLJ decision.
VBR-2 (3/16) Voluntary Binding Review Parameters of Acceptance Agreement Section 32 WCL Parties of Interest Form must be signed by all parties of interest and filed with the Board by E-fax ((518) 402-7115), Email (vbrform@wcb.ny.gov) or Web Upload Within 30 days of the date on which the Board requests that the parties complete the Parameters of Acceptance Settlement Agreement and submit it to the Board.
VDF-1 (1/12)

[VDF-1 Online 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-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 (9/16) 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/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
328 State Street Schenectady, NY 12305-2318
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)
W-32-I (10/18) WAMO Settlement Agreement – Indemnity - Section 32 WCL Parties of Interest To obtain WAMO signature, mail to:
Waiver Agreement Management Office (WAMO)
NYS Workers' Compensation Board
328 State Street Schenectady, NY 12305-2318
When all POIs have signed, mail to WCB Centralized Mailing Address.
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.
W-32-IM (10/18) WAMO Settlement Agreement – Indemnity/Medical - Section 32 WCL Parties of Interest To obtain WAMO signature, mail to:
Waiver Agreement Management Office (WAMO)
NYS Workers' Compensation Board
328 State Street Schenectady, NY 12305-2318
When all POIs have signed, mail to WCB Centralized Mailing Address.
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.
WTC-12 (9/18) 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, 2022
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 (3/17) 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 Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 After filing a timely WTC-12, file a claim. See form for complete instructions.
WTC-VCF-AUTH (4/17) World Trade Center September 11th Victim Compensation Fund (VCF) Authorization Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board File with Form WTCVol-3. See form for complete instructions.
WTC-HIPAA (4/17) World Trade Center Volunteer Health Insurance Portability and Accountability Act Authorization Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board File with Form WTCVol-3. See form for complete instructions.

If the form you are looking for is not listed above, or in the list of Common Board Forms, please email the Board's Forms Department.

View a list of all prescribed Workers' Compensation Board forms