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. Please enter your information, select print and choose Microsoft Print to PDF and submit the saved PDF. Please note, that if you do not Print to PDF, the entered data may not be transmitted resulting in a blank form being submitted. 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 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.
Current Versions of Forms
WCB periodically releases new versions of certain forms to obtain additional information, streamline processing, and/or make it easier to complete the form. These changes are often extensive, and it is important for all stakeholders to use the same form so that information is consistent. As such, WCB may announce that it will not accept older versions of an updated form after a certain date. The table below has the most recent version of each form, and where older versions are no longer accepted, includes the notation "Only current version accepted."
Original Signature Requirement
Popular Forms
- C-8.1B Notice of Objection to a Payment of a Bill for Treatment Provided
- RFA-2 Request for Further Action by Insurer/Employer
| Form Number / Version Date |
Form Title | Who Files | Where to File | When to File |
|---|---|---|---|---|
|
C-2F (9/23) 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 10 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-8.1B (7/22) Paper Version
The Board will only accept the current version of this form. WCB COVID-19 Guidance: Attaching Medical Bills to Form C-8.1B See Subject No. 046-1362R3 – Important Updates Regarding Forms C-8.1 and C-8.4, Including Implementation Dates Related to the CMS-1500 Initiative [C-8.1B Online Submission] |
Notice of Objection to a Payment of a Bill for Treatment Provided | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to employee and their 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. When submitting the objection forms C-8.1B and C-8.4 with supporting attachments in the same submission, the attachments will be placed behind the C-8.1B and the C-8.4 will be processed as a single document. If attachments are required behind both the C-8.1B and the C-8.4, please submit these two forms separately from each other with their corresponding attachments. |
| C-8.4 (7/22)
The Board will only accept the current version of this form. See Subject No. 046-1362R3 – Important Updates Regarding Forms C-8.1 and C-8.4, Including Implementation Dates Related to the CMS-1500 Initiative 05/03/2022 – Form C-8.4 Updates |
Notice to Health Care Provider and Claimant of an Insurer'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 their 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.
When submitting the objection forms C-8.1B and C-8.4 with supporting attachments in the same submission, the attachments will be placed behind the C-8.1B and the C-8.4 will be processed as a single document. If attachments are required behind both the C-8.1B and the C-8.4, please submit these two forms separately from each other with their corresponding attachments. |
| 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-32 (4/21)
The Board will only accept the current version of this form. |
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 (1/24)
The Board will only accept the current version of this form. 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 (1/24)
The Board will only accept the current version of this form. |
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)
The Board will only accept the current version of this form. |
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)
The Board will only accept the current version of this form. |
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-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’ compensaion insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent. It is normally provided in the insurance policy package. |
| 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. |
| C-105.2 (9/17) | Certificate of NYS Workers' Compensation Insurance Coverage (All private NYS licensed workers' compensation carriers are required to issue the C-105.2. Please note that the State Insurance Fund issues a different form, the U-26.3 form, as its version of the C-105.2) | Employers insured for workers' compensation through a private insurance carrier | Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The C-105.2 must be completed by the insurance carrier or its licensed insurance agent. | Employers must obtain this form from either their NYS workers' compensation insurance carrier or a licensed NYS insurance agent of that carrier. |
| 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 (6/17) Paper Version [C-240 Online Submission] |
Employer's Statement of Wage Earnings Preceding Date of Accident | Employer | Workers' Compensation Board | Within 10 days of request by the Board. |
| C-251 (11/22) (MS Excel) |
Insurer's Request Reimbursement of Indemnity Payments Under WCL Section 14(6) or Section 15(8) | Insurance Carrier/Board-approved self-insurer | Email completed form to: SpecialFunds@wcb.ny.gov | For twenty-six week periods, per form instructions. |
| C-251.1 (5/22) | Insurer's Request for Reimbursement of Medical Payments Under WCL Section 15(8) | Insurance Carrier/Board-approved self-insurer | Email completed form to: SpecialFunds@wcb.ny.gov or Mail completed form to: NYS Workers’ Compensation Board Attention: Special Funds Group 328 State Street, Room 331 Schenectady, NY 12305 | For twenty-six week periods, per form instructions. |
| C-251.4 (11/21) (MS Excel) |
Insurer's Request For Reimbursement Of Indemnity Payments Under WCL §25-a(9) | Insurance Carrier/Board-approved self-insurer | Email completed form to: SpecialFunds@wcb.ny.gov | |
| C-251.6 (5/22) | Insurer's Request for Reconsideration of Reduction Under WCL Section 14(6) or Section 15(8) | Insurance Carrier/Board-approved self-insurer | Email completed form to: SpecialFunds@wcb.ny.gov | |
| C-251N (5/22) | Insurer's Notification of Initial Request for Reimbursement Under Section 14(6) or Section 15(8) | Insurance Carrier/Board-approved self-insurer | Email completed form to: SpecialFunds@wcb.ny.gov | |
| C-300.5 (10/16)
The Board will only accept the current version of this form. |
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)
The Board will only accept the current version of this form. |
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 (5/23) | 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. |
| 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. |
| 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 their representative, and health provider. | To Claimant when the statement of Claimant's Rights is mailed - within 14 days of receipt of initiating FROI, or with first check per WCL 110, or when the carrier contracts with a DTN To medical provider when carrier contracts with a DTN, or at time of first medical bill. |
| IME-5 (5/18)
Implementation of Forms Associated with SLU Evaluations |
Claimant's Notice of Independent Medical Examination | Claim Administrator/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. |
| OC-110AORD (4/18) | Request for Judicial Order – Access to Case Files | Individuals or Entities not considered parties in interest who are seeking access to case files | Workers' Compensation Board | As needed. This form may be submitted in person at any Board office, mailed or faxed ((877) 533-0337) to the Board. |
| OC-400.5 (6/13)
The Board will only accept the current version of this form. |
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 (10/18) Paper Version [PH-16.2 Online Submission] Adobe Format Overview/Features |
Pre-Hearing Conference Statement | Claimant's Attorney or Licensed Representative; Carrier or Board-approved self-insured employer | Workers' Compensation Board, with copies served on all other parties of interest. | 10 days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04). |
| R (8/05) | Carrier's Report on Rehabilitation | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to claimant and their 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 (4/24) | 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 (4/24) | 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 (4/24) | 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 (4/24) | 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 (8/23) Paper Version
The Board will only accept the current version of this form. [RFA-2 Online Submission] 04/29/2022 - RFA Process Updates |
Request for Further Action by Insurer/Employer | Insurance Carrier or Board-approved self-insured employer | Workers' Compensation Board, with copies to claimant and their 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. |
| 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 |
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.