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Glossary of WCB Terms

Workers' Compensation Forms for Insurance Carriers,
Self-Insured Employers and Third Party Administrators

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.

Popular Forms

 

All Insurance Carriers, Self-Insured Employers and Third Party Administrators Forms

Form Number /
Version Date
Form Title Who Files Where to File When to File
C-2F (1/14) Paper Version

[C-2F Instructions]

C-2
(obsolete)
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-7
(obsolete)


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
(obsolete)
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 (12-14) 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-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-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-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-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 (7/14)

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-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
(obsolete)
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.
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.
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.
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
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-400.5 (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.
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.
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-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 (7/09) Affidavit Certifying That Compensation Has Been Secured Employers with Board-approved self-insurance for workers' compensation Filed with the government agency issuing a permit, license or contract. The SI-12 must be completed by the Board's Self-Insurance Office and approved by the Board's Secretary. Upon obtaining a permit, license or contract from a government agency. Board-approved self-insurers must obtain this form from Board's Self-Insurance Office. (518) 402-0247
U-26.3 NY State Insurance Fund Certificate of Workers' Compensation Coverage (This is the State Insurance Fund's equivalent of Workers' Compensation Board Form C-105.2) Employers insured for workers' compensation through the State Insurance Fund Filed with the government agency issuing a permit, license or contract. Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from the State Insurance Fund.
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
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.