Instructions for Completing Form C-3, "Employee Claim"
A. Your Information (Employee)
- Enter your full name, including first name, middle initial, and last name .
- Enter your mailing address, including P.O. Box, if applicable, city or town, state, and zip code .
- Enter your date of birth in month/day/year format. Include the four digit year.
- Enter your Social Security Number. This is very important to help service your claim faster .
- Indicate the primary contact phone number, including area code. This may include a cell phone number.
- Indicate your gender (Male or Female).
- Board hearings are conducted in English. If you will need a translator to understand the proceeding, the Board will provide one. Check Yes and indicate the language needed.
B. Your Employer(s)
- Indicate the employer you were working for at the time you were injured or became ill.
- Enter the employer's address, including P.O. Box, if applicable, city or town, state, and zip code.
- Enter the phone number for this employer, either a primary contact number or the number for your supervisor .
- Indicate the date you were hired by this employer.
- Enter your direct supervisor's name, the person you report to on a regular basis.
- If you have more than one job, please indicate the names and addresses of all other employers you work for besides the one you were injured at.
- Check Yes if you lost time from any of your other jobs as a result of your injury or illness; otherwise, check No.
C. Your Job
- Indicate your current job title or job description (e.g., warehouse worker).
- Indicate your typical work activities for this job (e.g., keeping inventory, unloading trucks, etc.)
- Check the type of job you had.
- Enter your gross pay (before taxes) per pay period.
- Indicate how often you received a paycheck (weekly, bi-weekly, etc.).
- Indicate if you received any tips or lodging in addition to your regular pay. If you did, describe them.
D. Your Injury or Illness
- Enter the date when you were injured or the first date you noticed you became ill. Enter the date in month/day/year format. Include the four digit year.
- Enter the time when the injury occurred. Check whether it was AM or PM. Skip this question if this is an illness or occupational disease.
- Indicate the location where the injury/illness occurred, including the address of the building and the physical location in the building where the injury/illness happened.
- Check whether this was your normal work location. If it was not, explain why you were at this location.
- Describe in detail what you were doing at the time of the injury/illness (e.g., unloading boxes from a truck by hand). This explains the events leading up to the injury.
- Describe in detail how the injury/illness occurred (e.g., I was lifting a heavy box off a truck). This should include all people and events involved in the injury/illness.
- Indicate fully the nature and extent of your injury/illness, including all body parts injured. Be as specific as possible. (e.g., I strained my back trying to lift a heavy box. It hurts to bend over or hold even lighter objects now.)
- Indicate if some object was involved in the accident OTHER THAN a licensed motor vehicle. Other objects may include a tool (e.g., hammer), a chemical (e.g., acid), machinery (e.g., forklift or drill press), etc.
- Indicate if a licensed motor vehicle was involved in the accident. If so, check if the motor vehicle involved was yours,
your employer's, or belonged to someone else. Include the license plate number (if known). If your vehicle was involved, fill out the name and address of your automobile insurance carrier.
- Indicate if you gave your employer or supervisor notice of your injury or illness. If so, indicate who you gave notice to as well as if it was orally or in writing. Include the date you gave notice.
- Check if anyone saw the injury happen. If anyone saw it, include their name(s).
E. Return to Work
- If you stopped working as a result of your work-related injury/illness, check Yes and indicate on what date you stopped working. If you have not stopped working, check No.
- If you have since returned to work, check Yes. Also indicate on what date you started working again, as well as if you have returned to your Normal Duties or if you are on Limited or Restricted Duty. (If you have not returned to your full pre-injury or illness work duties, then you are on Limited Duty.)
- If you have returned to work, indicate who you are working for now.
- Enter your gross pay (before taxes) per pay period for the job you are working at now. Indicate how often you are receiving a paycheck (weekly, bi-weekly, etc.).
F. Medical Treatment
The question numbers for Section F change based on your responses to the questions.
- Indicate if you received medical treatment for this injury/illness. If you did not receive medical treatment, check None received.
- If you did receive treatment, enter the date you first received treatment for this injury/illness and complete the rest of this section.
- Check if you were first treated on the job for this injury or illness.
- Check the location where you first received off site medical treatment for your injury or illness. Include the name and address of the facility as well as the phone number (including area code).
- If you are still receiving ongoing treatment for the same injury or illness, check Yes and indicate the name and address of the doctor(s) providing treatment as well as the phone number (including area code); otherwise check No.
- If you believe you already had an injury to the same body part or a similar illness, check Yes and indicate if you were treated by a doctor for this injury or illness. If you were treated by a doctor, indicate the name(s) and address(es) of the doctor(s) whom provided care and complete and file form C-3.3.
- If you had a previous injury or illness, check if your previous injury or illness was work-related. If Yes, check if the injury or illness happened while working for your current employer.
- Indicate if you are the employee or if you are completeing the form on behalf of the employee.
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.
- Enter your first and last name.
- The date will pre-fill with today's date.
- 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 or C-7) and mail it to the Board.