Skip to Content

Workers’ Compensation Board

Search menu

OnBoard will be temporarily unavailable for scheduled maintenance from 6:00 p.m. ET Thursday, October 6, 2022, through 7:00 a.m. ET Friday, October 7, 2022. Prior authorization requests with a due date of October 6, 2022 will be extended to October 7, 2022.

Save the Date – COVID-19 and Workers’ Compensation Webinars

Language Access Policy  |  Disclaimer Regarding the Use of "Google Translate"

Workers’ Compensation Forms Injured Workers

Forms

Completing Forms

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

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

Multi-page Forms
Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.

Original Signature Requirement

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

The Workers' Compensation Board does not normally accept a claimant's electronic signature on Board-prescribed forms. Due to recent increases in COVID-19 infection rates across New York State, however, as of August 16, 2021, the Emergency Relief from Signature Requirements on Listed Documents will remain in effect until further notice for the forms specifically listed in the Board's announcement: Emergency Relief from Original Signature Requirements on Listed Documents.

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


Popular Forms


Workers' Compensation Forms for Injured Workers
Form Number /
Version Date
Form Title Who Files Where to File When to File
A-9 (11/21) 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.
AFF-1 (6-16) Affidavit For Death Benefits Claimant (see when to file) Workers' Compensation Board This affidavit is to be used by a surviving spouse or the dependent child(ren) of the deceased; by dependent brothers/sisters/grandchildren; by dependent parents/grandparents. It can also be used by the non-dependent parents or the estate of the deceased where there is no surviving spouse or other dependents.
Claimant Quick Start Guide (Claimant Information Packet)

Claimant Quick Start Guide (Claimant Information Packet) Employers or their designees, such as third-party administrators or insurance carriers. (Note: The Claimant Information Packet is not filed with the Board) Provided to an injured worker immediately after a work-related accident or exposure. When an employee is injured due to a work-related accident or becomes ill due to exposure, the employer or its designee must provide the injured worker with the Claimant Information Packet as soon as possible.
C-3 (6/22) Paper Version

[C-3 Online Submission]

[C-3 Instructions]
Employee Claim Employee Workers' Compensation Board, in the event of on-the-job injury or illness. Within two years of accident, or within two years after employee knew or should have known that injury or illness was related to employment.
C-3.1 (3/04)
C-3.1S (Spanish version) on reverse
Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider Employee Completed by injured employee when employer who is not part of a PPO or ADR program wishes to recommend a network or provider to such employee for treatment purposes. The form is maintained by employer and is not submitted to the Board. The consent shall not be executed prior to the occurrence of employee's work-related injury or illness, but must be executed prior to an employer, who is not part of a PPO or ADR program, recommending a network or provider to an injured employee for treatment purposes.
C-3.3 (12/09) Limited Release of Health Information (HIPAA) Claimant Workers' Compensation Board If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current Claim, fill out this form.
C-25 (6/22) 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-32 (4/21) Waiver Agreement - Section 32 WCL Parties in Interest Form must be signed by all parties in interest and mailed to WCB (or presented at hearing). Agreement may be filed at any time during an open and pending case, and may cover any and all issues
C-32.1 (2/16)

Video: Settling Your Claim
Section 32 Settlement Agreement: Claimant Release Party Submitting Section 32 Settlement Agreement Workers' Compensation Board Completed and notarized Form C-32.1 must be filed along with Form C-32, Section 32 Agreement.
C-32AF (12-21) Carrier's/Self-Insured Employer's Affirmation Insurance Carrier, Self-Insured Employer or Third-Party Administrator Workers' Compensation Board Filed as an attachment to the C-32 agreement.
C-32E (7/19) Section 32 - Electronic Signature Insurance Carrier, Self-Insured Employer or Third-Party Administrator Workers' Compensation Board Filed as an attachment to the C-32 agreement.
C-32-I (6/20) Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement Parties in Interest Form must be signed by all parties in interest and mailed to WCB (or presented at hearing) Agreement may be filed at any time during an open and pending case, and may cover any and all issues.
C-35 (4-17) Extreme Hardship Redetermination Request Section 35(3) of the Workers' Compensation Law Injured Worker Workers' Compensation Board When an injured worker is requesting a redetermination due to an extreme hardship as described in Section 35(3) of the Workers' Compensation Law and has been classified with a permanent partial disability with a loss of wage earning capacity of greater than 75% and capped benefits will expire within one year.
C-62 (1/11) Claim for Compensation in Death Case Claimant (The claimant is the surviving spouse, child or dependent of the deceased. See the reverse of the form for details on who may file a claim in a death case.) Workers' Compensation Board in the event of on-the-job death. Within two years of accidental death.
C-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-257 (11/21) Claimant's Record of Medical and Travel Expenses and Request for Reimbursement Claimant Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. As needed. Include copies of all receipts and bills, if possible.
C-258 (5/19) Claimant's Record of Job Search Efforts/Contacts Claimants who are partially disabled and are not employed or working, except a claimant who was entitled to benefits at the time he/she was classified with a permanent partial disability. This form and all documents supporting your job search efforts must be submitted to the Board in advance of your hearing, or brought with you on the date of your hearing and will be collected by the WC Law Judge. Please refer to the detailed instructions on page two of this form for where/when to file this form. This form is used to record efforts made to search for work within the claimant's medical restrictions and with the assistance of an agency or employment counselor.

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

Please refer to the detailed instructions on page two of this form for where/when to file this form.
C-300.5 (10/16) Stipulation Employee (and Attorney or Representative, if represented) and Carrier/Board-approved self-insurer Workers' Compensation Board To be used for stipulations to uncontested facts or proposed findings, pursuant to 12NYCRR 300.5.
C-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-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 (2/22) Statement of Rights (WCL) Insurance Carrier/Board-approved self-insurer Sent to injured employee. Within 14 days of receipt of initiating FROI, or with initial benefit check, whichever is earlier.
DC-120 (7/17) Discharge or Discrimination Complaint Employee who is alleging that an employer has discharged or discriminated against him/her because he/she has claimed or attempted to claim compensation File in duplicate:
Workers' Compensation Board
Discrimination Unit
Riverview Center - 150 Broadway
Menands, NY 12204
Any complaint alleging an unlawful discriminatory practice must be filed within two years of the commission of such practice.
DD-1 (5/21) Direct Deposit Authorization Sample Form To begin, change or cancel the transmittal of workers' compensation benefit checks and/or proceeds from a settlement agreement pursuant to WCL § 32 directly to a financial institution. This is a sample form only. Claimant should fill out the form on their insurer or administrator's website and submit the form directly to them. Insurance Carrier or Board-approved self-insured employer.
DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD.
Please read all information and instructions on the front of the form.
DD-2 (9/05) Biannual Recertification to Entitlement to Benefits A claimant who is having benefit checks directly deposited in a financial institution. Insurance Carrier or Board-approved self-insured employer.
DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD.
Every six months, upon receipt of the form from the carrier/Board-approved self-insured employer.
DT-1 (3/12) Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider Insurance or Diagnostic Testing Network (DTN) can use DT-1 form or a substantially equivalent form to identify one or more DTNs Copy to employee and his/her representative, and health provider. To Claimant when the statement of Claimant's Rights is mailed - within 14 days of 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.

LAC-1 (07-22)

[LAC-1 Online Submission]

Right to File a Language Access Complaint

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.
OC-110A (12/17) Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) Claimant Workers' Compensation Board Claimant must submit form with original signature in order to allow release of his/her records to parties not otherwise authorized to receive them.
RB-89 (9/21) Application for Board Review

Note: 9/21 version is only an update to instructions. Both 11/18 and 9/21 versions will be accepted by the Board.
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 (9/21) Rebuttal of Application for Board Review

Note: 9/21 version is only an update to instructions. Both 11/18 and 9/21 versions will be accepted by the Board.
Party rebutting application for Board Review of WC Law Judge decision Workers' Compensation Board, copy to all other parties of interest. Within 30 days after service of the application for review upon the party making the rebuttal.
RB-89.2 (11/18) Application for Reconsideration / Full Board Review Party applying for Full Board Review of Board Panel decision. Workers' Compensation Board, copy to all other parties of interest. Within 30 days after notice of filing the decision of the Board Panel.
RB-89.3 (11/18) 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 (5/22) Paper Version


[RFA-1W Online Submission]
Request for Assistance by Injured Worker Claimant Workers' Compensation Board The form may be filed at any time after the Board assigns a WCB case number, or any time after the Board has indicated that no further action (NFA) will be taken.
VDF-1 (1/12)

[VDF-1 Online Submission]
Loss of Wage Earning Capacity Vocational Data Form Claimant Workers' Compensation Board, copy to insurance carrier Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.
WTC-12 (9/22) 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, 2026
WTC-HIPAA (4/17) World Trade Center Volunteer Health Insurance Portability and Accountability Act Authorization Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board File with Form WTCVol-3. See form for complete instructions.
WTC-VCF-AUTH (4/17) World Trade Center September 11th Victim Compensation Fund (VCF) Authorization Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board File with Form WTCVol-3. See form for complete instructions.
WTCVol-3 (6/22) World Trade Center Volunteer's Claim for Compensation Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 After filing a timely WTC-12, file a claim. See form for complete instructions.

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