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Employee Claim

State of New York - Workers' Compensation Board


Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness.

Required items are indicated by an *

A. Your Information (Employee)

* Gender:
* Will you need a translator if you have to attend a Board hearing?
B. Your Employer(s)
Did you have more than one employer at the time of your injury/illness?
List names/addresses of any other employer(s) at the time of your injury/illness:


Did you lose time from work at the other employment(s) as a result of your injury/illness?
C. Your Job on the date of the injury or illness
* Was your job?
* Did you receive lodging or tips in addition to your pay?
D. Your Injury or Illness
* Was this your usual work location?
* Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?
* Was the injury the result of the use or operation of a licensed motor vehicle?
If Yes:

If your vehicle was involved, give name and address of your motor vehicle insurance carrier:
* Have you given your employer (or supervisor) notice of injury/illness?
If yes, notice was given to:
Notice was given:
* Did anyone see your injury happen?
E. Return To Work
* Did you stop work because of your injury/illness?
Have you returned to work?
    If you have returned to work, who are you working for now?

F. Medical Treatment For This Injury or Illness
* Did you receive treatment for your injury or illness?
Were you treated on site?
Where did you receive your first off site medical treatment for your injury/illness?

Name and Address of where you were first treated off site:

Are you still being treated for this injury/illness?
Give the name and address of the doctor(s) treating you for this injury/illness.
Add additional doctor's if there is more than one doctor still treating you for this injury/illness


* Have you had another injury to the same body part, or a similar illness?
If yes, were you treated by a doctor?
Was the previous injury/illness work related?
If yes, were you working for the same employer that you work for now?
G. Prepared By

Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.

Please Note: If you have retained a legal representative at the time of filling out this on-line EC-3, then you must notify your legal representative that they must complete and sign form OC-400.5 (Attorney/Representative's Certification of form C-3) and mail it to the Board.

An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.

* Prepared By: