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Workers' Compensation Board Common Forms


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Forms are in PDF format. The Board recommends using the latest version of Adobe Reader Link to External Website 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.
A-9C (10/12) 关于在未提起诉讼、诉讼驳回或 WCL §32 项下协议获得批准的情况下需支付医疗费用的通知
A-9H (10/12)

SONJE OU KA RESPONSAB POU DEPANS MEDIKAL SIZOKA OU PA ALE NAN LAJISTIS, OSWA SI OU JWENN REFI POU REKLAMASYON KONPANSASYON, OSWA SI OU JWENN APWOBASYON POU AKÒ DAPRE SEKSYON 32 WCL
A-9I (10/12)

ATTENZIONE: LE SPESE MEDICHE POTREBBERO ESSERE RITENUTE A SUO CARICO IN CASO DI ABBANDONO O DI MANCATA APPROVAZIONE DELLA RICHIESTA DI INDENNIZZO O QUALORA SI APPROVI UN ACCORDO TRA LE PARTI SECONDO QUANTO STABILITO ALLA §32 DELLA WCL
A-9K (10/12)

WCB보상 청구를 수행하지 않거나 보상 청구가 각하되거나 또는 WCL §32에 따른 합의가 승인되는 경우 귀하는 의료비에 대한 책임이 있을 수 있습니다.
A-9P (10/12)

NINIEJSZYM ZWRACAMY UWAGĘ, ŻE W PRZYPADKU NIESKUTECZNEGO ZŁOŻENIA WNIOSKU, NIEUZNANIA ROSZCZENIA O ODSZKODOWANIE LUB W RAZIE ZATWIERDZENIA POROZUMIENIA ZGODNEGO Z §32 PRZEPISÓW DOTYCZĄCYCH ODSZKODOWAŃ ZA WYPADKI PRZY PRACY (WCL) OSOBA POSZKODOWANA MOŻE PONIEŚĆ KOSZTY USŁUG MEDYCZNYCH
A-9R (10/12) ИЗВЕЩЕНИЕ О ТОМ, ЧТО ВЫ МОЖЕТЕ НЕСТИ ОТВЕТСТВЕННОСТЬ ЗА РАСХОДЫ НА ЛЕЧЕНИЕ В СЛУЧАЕ НЕПРЕДЪЯВЛЕНИЯ ЗАЯВЛЕНИЯ ИЛИ ОТКЛОНЕНИЯ ЗАЯВЛЕНИЯ О КОМПЕНСАЦИИ ИЛИ ПРИ ОДОБРЕНИИ СОГЛАШЕНИЯ В СООТВЕТСТВИИ С §32 ЗАКОНА О КОМПЕНСАЦИЯХ РАБОТНИКАМ
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-2F (5/13) Paper Version

[C-2F Instructions]

C-2 (1/11) Paper Version

[C-2 Instructions]

[C-2 On-line Submissions]
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
(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) Reclamo 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-3C (10/12) 员工索赔
C-3H (10/12) Demann Anplwaye
C-3I (10/12) Richiesta di indennizzo da parte del dipendente
C-3K (10/12) 직원 청구서뉴욕주
C-3P (10/12) Wniosek pracownika
C-3R (10/12) Заявление работника
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-3.1C (10/12) 关于选择劳工赔偿局授权医疗服务提供者的权利的通知
C-3.1H (10/12) Avi pou Dwa pou Chwazi yon Founisè Swen Sante ki Gen Otorizasyon Komisyon Konpansasyon Travayè
C-3.1I (10/12) Informativa sul diritto di scelta di un professionista/struttura sanitaria autorizzato dalla Workers' Compensation Board
C-3.1K (10/12) 근로자재해보상위원회가 승인한 의료 제공자를 선택할 권리에 관한 통지서
C-3.1P (10/12) Informacja o prawie do wyboru dostawcy usług medycznych zatwierdzonego przez Komisję ds. Odszkodowań Pracowniczych
C-3.1R (10/12) Извещение о праве выбора поставщика медицинских услуг, уполномоченного Управлением по компенсациям работникам
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-3.3S (10/12) Divulgación limitada de información sobre la salud
C-3.3C (10/12) 健康信息的有限披露 (HIPAA)
C-3.3H (10/12) Divilgasyon Limite Enfòmasyon sou Sante (HIPAA)
C-3.3I (10/12) Richiesta di divulgazione parziale delle informazioni sanitarie (HIPAA)
C-3.3K (10/12) 건강 정보의 제한적 공개 (HIPAA)
C-3.3P (10/12) Ograniczony zakres ujawniania informacji o stanie zdrowia (HIPAA)
C-3.3R (10/12) Ограниченное разрешение на предоставление информации о состоянии здоровья (Закон о преемственности страхования и отчетности в области здравоохранения/HIPAA)
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 (1/12)
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 (2-13)
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 (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 (2-13) 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-62S (10/12) RECLAMO DE COMPENSACIÓN EN CASO DE FALLECIMIENTO DEL TRABAJADOR
C-62C (10/12) 死亡情况下的索赔
C-62H (10/12) REKLAMASYON POU KONPANSASYON NAN YON KA LANMÒ
C-62I (10/12) RICHIESTA DI INDENNIZZO IN CASO DI MORTE
C-62K (10/12) 사망 케이스의 보상 청구
C-62P (10/12) WNIOSEK O ODSZKODOWANIE Z TYTUŁU ZGONU
C-62R (10/12) ЗАЯВЛЕНИЕ НА ВЫПЛАТУ КОМПЕНСАЦИИ В СЛУЧАЕ СМЕРТИ РАБОТНИКА
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
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-105.21 (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,
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)Link to External Website 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-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 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 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,
328 State Street Schenectady, NY 12305-2318
For twenty-six week periods, if possible.
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 Link to External Website 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 (12/13) 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-120.2 (2/13) Certificate of Participation in Disability Benefits Group Self-Insurance Employers participating in disability benefits group self-insurance plans for workers' compensation 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 email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
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.
DB-450 (2/04) Aviso y prueba de reclamo por beneficios de discapacidad Empleado Presentar ante el empleador o su compañía de seguros si usted se convierte en discapacitado mientras estaba como empleado o dentro de un período de 4 semanas posteriores a la rescisión. Presente antes de los 30 días después de enfermarse o encontrarse como discapacitado.
Tenga en cuenta: Hay un espacio en blanco en el reverso de este formulario para la Declaración del empleador (Parte C). No es requerido por la Junta de compensación para los trabajadores, pero puede agregarse a discreción de la compañía aseguradora.
DB-450 (2/04) Notice and Proof of Claim for Disability Benefits 員工 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.
DB-450 (2/04) Avi ak Prèv Reklamasyon pou Avantaj akòz Andikap >Anplwaye Ranpli fòm nan avèk patwon an oswa avèk konpayi asirans li si ou vin andikape pandan w ap travay oswa nan 4 semèn apre revokasyon ou. Fè reklamasyon an nan egzakteman 30 jou apre ou vin malad oswa andikape.

Tanpri sonje: Gen espas vid ki disponib sou lòt bò fèm sa a pou yon Deklarasyon Patwon an (Pati C). Li pa obligatwa pou Komisyon Konpansasyon an, men ou ka mete li selon desizyon konpayi asirans lan.
DB-450 (2/04) Comunicazione e Bozza di ricorso >Dipendente Presentare al datore di lavoro o alla sua compagnia di assicurazione in caso di sopravvenuta disabilità durante la durata del contratto di lavoro o entro 4 settimane dalla sua conclusione. Presentare entro 30 giorni dalla sopravvenuta malattia o disabilità.

Nota: Sul retro di questo modulo è disponibile uno spazio bianco per una dichiarazione del datore di lavoro (Parte C). Non è richiesta dal Workers Compensation Board, ma può essere aggiunta a discrezione dell'assicuratore.
DB-450 (2/04) 장애 보상 청구 및 증빙 >직원 고용중이거나 고용해지로부터 4주 이내인 경우 고용주 또는 보험사에 제출 아프거나 장애를 얻게 된 때로부터 30일 이내

참고 사항: 이 양식 뒷면의 공백에 고용주의 진술서 첨부 가능(Part C). 이는 직원 보상 위원회의 요구 사항은 아니지만 보험사 재량으로 추가될 수 있습니다.
DB-450 (2/04) Zawiadomienie i dowód roszczenia o zasiłki z tytułu niezdolności do pracy Pracownik Składane u pracodawcy lub jego firmy ubezpieczeniowej w przypadku niezdolności do pracy podczas zatrudnienia lub w ciągu 4 tygodni po rozwiązaniu stosunku pracy. Składane nie później niż 30 dni po zachorowaniu lub powstaniu niezdolności do pracy.

Uwaga! Puste miejsce na odwrocie tego formularza jest przeznaczone na oświadczenie pracodawcy (część C). Nie jest ono wymagane przez Komisję ds. Odszkodowań Pracowniczych, może być jednak dodane wg uznania.
DB-450 (2/04) Уведомление о заявлении и подтверждение заявления на получение пособий по инвалидности Работник Подавать работодателю или в страховую компанию работодателя в случае потери трудоспособно-сти в период трудоустройства или в течение 4 недель после увольнения. Подавать не позднее чем через 30 дней после возникновения заболевания или получения инвалидности.

Обратите внимание! Пустое поле для заявления работодателя имеется на оборотной стороне данного бланка (Часть С). Указанное заявление не требуется Комиссией по компенсационным выплатам работникам, но может быть добавлено по решению страховщика.
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 (8/13) Health Provider's Request for Decision on Unpaid Medical Bill(s) Health Provider Disputed Medical Bills Unit, 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 Medical Director's Office, 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 Disputed Medical Bills Unit 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,
100 Broadway - Menands, Albany, NY 12241
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,
100 Broadway - Menands, Albany, NY 12241
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 Medical Director's Office, 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.
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 (4-13) 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.
LAC-1S (10/12)

La política del Estado de Nueva York incluye proveer servicios lingüísticos en la prestación de servicios y programas públicos. Si usted cree que no se le ha brindado un servicio adecuado de interpretación o que se le ha negado un documento disponible en versión traducida, por favor solicite un formulario de queja y háganos saber su experiencia.

Formulario para Comentarios sobre el Acceso a Servicios de Idiomas
LAC-1C (10/12)

紐約州政策要求提供公共服務和計畫的語言協助。如認為我們未為您提供充分的口譯服務,或拒絕為您提供現有可用翻譯文件,請索取投訴表,向我們表達反饋意見。

语言服务意见表
LAC-1H (10/12)

Règleman Eta New York se pou bay aksè nan lang nan sèvis ak pwogram piblik yo. Si ou panse nou pa t ba ou sèvis entèpretasyon konvnab oswa si nou te ba ou refi pou yon dokiman tradui ki disponib, tanpri mande fòm plent nou an pou ban nou remak ou.

Fòm Kòmantè sou Aksè nan Lang
LAC-1I (10/12)

La politica di Stato di New York offre assistenza linguistica nei servizi e programmi pubblici. Se si ritiene di non avere ricevuto un servizio di interpretariato adeguato o se è stata rifiutata la traduzione di un documento, è possibile richiedere il nostro modulo di reclamo per comunicare il proprio feedback.

Modulo di reclamo sui servizi linguistici forniti
LAC-1K (10/12)

뉴욕주의 정책은 공공서비스와 프로그램들을 접근하는 언어를 제공하는 것 입니다. 만일 여러분께서 우리가 적절한 통역서비스 제공하지 않았거나 유효한 번역서류를 거부했다고 생각되시면, 귀하의 피드백을 주실 불만신고 양식을 요청하시기 바랍니다.

언어 접근 코멘트 양식
LAC-1P (10/12) Formularz zażalenia na brak dostępu do usług tłumaczeniowych
LAC-1R (10/12)

Руководящим принципом администрации штата Нью-Йорк является предоставление услуг языкового доступа к общественным службам и программам. Если вам кажется, что вам не предоставили надлежащие переводческие услуги или что вам отказали в доступе к тому или иному переведенному документу, попросите, пожалуйста, бланк жалобы и поделитесь с нами своим мнением об этом.

Бланк для комментариев относительно языковой доступности
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 (2-13) 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 (2-13) 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 (2-13) 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 (2-13) 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-110AC(10/12) 索赔人对劳工赔偿记录之披露授权
OC-110AH(10/12) OTORIZASYON MOUN KI MANDE KONPANSASYON POU DIVILGE DOSYE KONPANSASYON TRAVAYÈ
OC-110AI(10/12) AUTORIZZAZIONE DEL RICHIEDENTE ALLA DIVULGAZIONE DEGLI ATTI DELL'INDENNIZZO PER INFORTUNIO SUL LAVORO
OC-110AK(10/12) 뉴욕주 직원상해보험위원회 직원 상해보험 기록 공개에 대한 청구인의 승인
OC-110AP(10/12) UPOWAŻNIENIE DO UJAWNIENIA AKT SPRAWY O ODSZKODOWANIE PRACOWNICZE
OC-110AR(10/12) РАЗРЕШЕНИЕ ЗАЯВИТЕЛЯ НА РАСКРЫТИЕ СВОЕГО ДОСЬЕ ПО КОМПЕНСАЦИИ
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 (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-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

NEW [OT/PT-4 On-line
Submission
]
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 (3/14) 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
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
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.
VDF-1S (10/12) Pérdida de la capacidad de generar ingresos Formulario de datos profesionales
VDF-1C (10/12) 丧失赚取收入能力职业数据表
VDF-1H (10/12) Pèt Mwayen pou Touche Salè Fòm Enfòmasyon Pwofesyonèl
VDF-1I (10/12) Perdita della capacità di guadagno del salario Modulo per i dati professionali
VDF-1K (10/12) 임금획득능력의 상실 직업 데이터 양식
VDF-1P (10/12) Utrata możliwości zarobkowania Formularz danych na temat pracy zawodowej
VDF-1R (10/12) Потеря трудоспособности Бланк для информации о профессиональном образовании и трудовой деятельности
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:
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)
WC/DB-100 (9/07)
(obsolete)
See Form CE-200
WC/DB-101 (7/04)
(obsolete)
See Form CE-200
WTC-12 (11/13) 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, 2014
WTC-12S (11/13) Registro de participación en las operaciones de rescate, recuperación y/o limpieza del World Trade Center; Declaración jurada en virtud de la sección 162 de la Ley de compensación de trabajadores (WCL) Empleados o voluntarios que participaron en las operaciones de rescate, recuperación y limpieza del World Trade Center entre el 9-11-01 y 9-12-02. Junta de Compensación para los Trabajadores A más tardar el 11 de septiembre de 2014
WTC-12C (11/13) 参与世界贸易中心救援、恢复和/清理行动登记: (依照 WCL §162 宣誓声明) 于 2001 年 9 月 11 日至 2002 年 9 月 12 日之间参加世界贸易中心救援、恢复和清理行动的雇员或志愿者。 劳工赔偿局 不迟于2014年9月11日
WTC-12H (11/13) Enskripsyon pou Patisipasyon nan Operasyon Sekou, Redrèsman ak/oswa Netwayaj na World Trade Center: Deklarasyon sou Sèman Dapre WCL §162 Anplwaye oswa volontè ki te patisipe nan Operasyon Sekou, Redrèsman ak/oswa Netwayaj na World Trade Center ant 11 septanm 2001 ak 12 septanm 2002. Komisyon Konpansasyon Travayè Anvan 11 septanm 2014
WTC-12I (11/13) Registrazione di partecipazione alle operazioni di soccorso, recupero e/o rimozione di detriti relative al World Trade Center: dichiarazione giurata ai sensi del Comma 162 della WCL Dipendenti o volontari che abbiano partecipato alle operazioni di soccorso, recupero e rimozione di detriti relative al World Trade Center nel periodo compreso tra l'11-09-01 e il 12-09-02. Workers' Compensation Board (Comitato infortuni sul lavoro) Entro e non oltre l'11 settembre 2014
WTC-12K (11/13) 월드트레이드센터 구조, 복구 및/또는 청소 업무 참가 등록: 근로자 보상법(WCL) 162에 따른 선서진술서 2001년 9월 11일과 2002년 9월 12일에 월드트레이드센터 구조, 복구 및/또는 청소 업무에 참가한 피고용자 또는 자원봉사자. 근로자 보상 위원회 2014년 9월 11일까지 제출
WTC-12P (11/13) Zgłoszenie uczestnictwa w akcji ratowniczej, usuwaniu skutków katastrofy i/lub czynnościach porządkowych wykonywanych na terenie World Trade Center: Oświadczenie pod przysięgą zgodne z §162 WCL Pracownicy lub wolontariusze, którzy uczestniczyli w akcji ratowniczej, usuwaniu skutków katastrofy i/lub czynnościach porządkowych wykonywanych na terenie World Trade Center w okresie od 11 września 2001 do 12 września 2002 Worker’s Compensation Board (Urząd Odszkodowań Pracowniczych) Do 11 września 2014 r.
WTC-12R (11/13) Регистрация факта участия в спасательных, восстановительных работах и (или) разборе завалов Всемирного торгового центра: заявление под присягой в соответствии со ст. 162 Закона о компенсации работникам Работники или волонтеры, принимавшие участие в спасательных, восстановительных работах и разборе завалов Всемирного торгового центра в период с 11 сентября 2001 г. до 12 сентября 2002 г. Совет по компенсациям работникам Не позднее 11 сентября 2014 г.
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
328 State Street Schenectady, NY 12305-2318
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 adobe pdf