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Employee Claim (C-3)– Adobe Format

This C-3 form uses Adobe Reader to render the form.   Adobe Reader® 9 or later, is recommended to support the additional functionality in this form. The latest version of Adobe Reader® Link to External Website is available as a free download from Adobe's web site.

Instructions for Completing Form C-3, "Employee Claim"

Form C-3.3 – Limited Release of Health Information (HIPAA) adobe pdf

Confirmation of Submission to the Board

After the Board receives your form, a non-editable PDF version of the form will appear in your web browser. The first page contains a confirmation that your form was successfully submitted to the Board and the date. It should be saved for your records. DO NOT MAIL THIS FORM TO THE BOARD.

If a confirmation page does not appear in your web browser after you submit the form to the Board, then the Board did not successfully receive the form and you will need to resubmit it.

PLEASE READ if you are using a Mac™ or Google Chrome™ or Firefox 19.0™ before selecting CONTINUE!