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Workers’ Compensation Forms Employers

Forms

Completing Forms

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

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

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

Certificates of Insurance
Forms C-105, C-105.1, C-105.2, DB-120, DB-120.1 and DB-155 are not available on this site. Contact your insurance carrier or licensed NYS insurance agent for these forms. Carriers and their licensed agents may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. Self-insured employers can contact the Office of Self-Insurance at selfinsurance@wcb.ny.gov for the Certificate of Self-Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law (Form DB-155).


Popular Forms


Workers' Compensation Forms for Employers
Form Number /
Version Date
Form Title Who Files Where to File When to File
ADR-1 (6/22) 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.
C-2F (1/14) Paper Version

[C-2F Instructions]
Employer's Report of Work-Related Injury/Illness Employer (contact your insurance carrier who can provide advice for the best method to report the information.) Workers' Compensation Board, copy to insurance carrier. Within ten days after occurrence of Injury/Illness.
Claimant 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-11 (6/22) Paper Version


[C-11 Online Submission]
Employer's Report of Injured Employee's Change in Status or Return to Work Employer Workers' Compensation Board As soon as employment status of injured employee changes.
C-105 (9/17) Notice of Compliance – Workers' Compensation Law Employers insured for workers' compensation through an insurance carrier or Board-approved self-insurance This form is not filed. It must be completed by the insurance carrier or self-insured administrator with identifying insurance information and then displayed by the employer in the workplace. Upon securing of workers' compensation insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
C-105.1 (9-05) Notice to Be Posted by Employers Under WCL for Automotive or Horse–Drawn Vehicles Employers insured for workers' compensation through an insurance carrier or Board-approved self-insurance This form is not filed. It must be completed by the insurance carrier, group Board-approved self-insurance administrator or Board-approved self-insured employer with identifying insurance information and then displayed by the employer in automotive or horse-drawn vehicles in accordance with Section 51 WCL. Upon securing of workers' compensation insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
C-105.2 (9/15) 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-105.3 (5-04) Notice of Election of an Incorporated Religious, Charitable, Educational, or U.S. War Veterans Organization to Bring Executive Officers under the Coverage of the new York Workers' Compensation law. Executive Officers Filed with the insurance carrier. File with the insurance carrier.
C-105.4 (11-96) Revocation of election of an incorporated religious, charitable, educational, or U.S. War Veterans organization to bring executive officers under the coverage of the New York Workers' Compensation Law Executive Officers Filed with the insurance carrier. File with the insurance carrier.
C-105.31 (1/04) Notice of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL Municipal Corporation or Political Subdivision File with insurance carrier. File with insurance carrier.
C-105.32 (4/04) Notice of Election of a Partnership, Limited Liability Partnership, Professional Limited Liability Partnership, Limited Liability Company, Professional Limited Liability Company or Sole Proprietorship to Bring Partners, Members or Self-Employed Persons Under the Coverage of the New York State Workers' Compensation Law Partnership or Sole Proprietorship File with insurance carrier. File with insurance carrier.
C-105.41 (1/04) Revocation of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL Municipal Corporation or Political Subdivision File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau,
328 State Street Schenectady, NY 12305-2318, and to each officer named on form.
Revocation is effective 30 days after date filed with WCB and insurance carrier.
C-105.51 (1/04) Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage Sole Shareholder Officer or Two Executive Officers of a corporation required to have workers' compensation coverage File with insurance carrier. Board-approved self-insured employers file with the WCB Self-Insurance Office. Board-approved group self-insured's file with the WCB Self-Insurance Office and also with your Group Administrator. As soon as the corporation wishes to exclude the sole shareholder-officer, or one of the two or both executive officers-shareholders of the corporation from workers' compensation coverage.
C-105.52 (1/04) Notice of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage Not-for-Profit Corporation or Unincorporated Association File with insurance carrier. Unsalaried executive officer is deemed included in insurance contract until election to exclude is filed.
C-105.53 (1/04) Revocation of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage Not-for-Profit Corporation or Unincorporated Association File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau,
328 State Street Schenectady, NY 12305-2318.
Revocation is effective 30 days after the date filed by the corporation or association with the insurance carrier and the WCB.
C-105.54 (3/99) Notice of Election to Bring Sheltered Workshop Participants Under Coverage of WCL Office or agency operating sheltered workshop File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau,
328 State Street Schenectady, NY 12305-2318.
File with insurance carrier.
C-105.55 (1/04) Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage Sole Shareholder Officer or Two Executive Officers of a corporation required to have workers' compensation coverage File with insurance carrier, copy to Chair, WCB, attn: Compliance Bureau,
328 State Street Schenectady, NY 12305-2318. If Board-approved self-insured employer, to WCB only.
Upon deciding to revoke election to exclude officer(s) from coverage.
C-107 Employer's Request for Reimbursement (NY State Insurance Fund) This is a New York State Insurance Fund form. If you are an employer insured by the NY State Insurance Fund, contact your local State Insurance Fund office for this form, or call toll-free (888) 875-5790.    
C-240 (6/17) Paper Version


[C-240 Online Submission]
Employer's Statement of Wage Earnings Preceding Date of Accident Employer Workers' Compensation Board Within 10 days of request by the Board.
CE-200 (12/08) Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage Applicants for permits, licenses or contracts from State, county or municipal agencies in New York State that are not required to carry NYS workers' compensation and/or disability benefits insurance coverage. Please file with the government agency that is issuing the permit, license or contract. (Examples: The New York City Department of Buildings or the New York State Department of Health) These exemption forms can ONLY be used to attest to a government entity that an applicant requesting a permit, license or contract from that government entity is not required to carry NYS workers' compensation and/or disability benefits insurance. (Instructions)

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.

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.