Workers' Compensation Forms for Insurance Carriers,
Self-Insured Employers and Third Party Administrators
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 web site.
After the form opens in your browser, you may complete the form by typing information on the form before you print it.
IMPORTANT: 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.
If you require assistance with completing these forms, please contact your local WCB District Office.
Please note: Forms C-105, C-105.1, C-105.2, DB-120 and DB-120.1 are not available on this site. Contact your insurance carrier for these forms.
Popular Forms
- C-8.1 Notice of Treatment Issue/Disputed Bill
- C-8/8.6 Notice That Payment of Compensation Has Been Stopped or Modified
- C-251 Carrier's Request for Reimbursement of Compensation Payments Under Section 15-8
- C-669 Notice to Chair of Carrier's Action on Claim for Benefits
- RFA-2 Carrier's/Employer's Request for Further Action
| Form Number / Version Date |
Form Title | Who Files | Where to File | When to File |
|---|---|---|---|---|
| C-2 (8-09) Paper Version [C-2 On-line Submission] [C-2 Instructions] |
Employer's Report of Work-Related Injury/Illness | Employer | Workers' Compensation Board, copy to insurance carrier. | Within ten days after occurrence of Injury/Illness. |
| CLAIMANT INFORMATION PACKET (which includes the two sided document, a C-3 form and C-3.3 form) Compendio Información Reclamante (Claimant Information Packet, Spanish) |
CLAIMANT INFORMATION PACKET (which includes the two sided document, a C-3 form and C-3.3 form) |
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. The employer or its designee must note on the C-2 form that the packet was given to the injured worker. |
| C-7 (8/09) Paper Version [C-7 On-line Submission] |
Notice That Right to Compensation is Controverted | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to employee and his/her representative, and all health providers . | On or before 18th day after disability or within 10 days after employer had knowledge of injury, whichever is greater or if the first notice of the accident or illness is a notice of indexing, then within 25 days of receipt of the notice of indexing. |
| C-8.1 (8/09) Paper Version [C-8.1 On-line Submission] |
Notice of Treatment Issue/Disputed Bill | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to employee and his/her 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. |
| C-8.4 (9/08) | Notice to Health Care Provider and Injured Worker of a Carrier'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 his/her representative, if any. | Within 45 days after bill is submitted. This form was designed specifically to provide carriers with a useful format for the notification of valuation objections. The use of this form is not required but is encouraged. |
| C-8/8.6 (8/09) Paper Version [C-8/8.6 On-line Submission] |
Notice That Payment of Compensation Has Been Stopped or Modified | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to employee and his/her representative. | Within 16 days after the date on which benefit payments were stopped or modified. |
| C-11 (8/09) Paper Version [C-11 On-line 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-22 (8/09) Note: Print form on 14 inch paper. |
Application for Approval of Non-Schedule Adjustment | Employee and Carrier/Board-approved self-insurer | Workers' Compensation Board (One copy only: quadruplicate filing is no longer required.) | This is a joint application by employee and carrier/employer to close case on a non-schedule adjustment. It must be signed by all parties in the case. |
| C-22b (11/01) (obsolete) |
Replaced by Form RFA-2 | |||
| C-32 (11/09) | Settlement Agreement, Section 32 |
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 (12/09) Replaces EC-32.1 effective 9-1-06 | 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, Settlement Agreement. |
| C-105 (8/09) | 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, self-insured administrator or the Board's Self-Insurance Office 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. Board-approved self-insurers may contact the Board's Forms Department. |
| 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. Board-approved self-insurers may contact the Board's Forms Department. |
| 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-105.2 (9/07) | 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 the government agency issuing a permit, license or contract. The C-105.2 must be completed by the insurance carrier or its licensed insurance agent. | Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their private insurance carrier. Carriers and their licensed agents may contact the Board's Bureau of Compliance to obtain this form. |
| C-240 (8/09) Paper Version [C-240 On-line Submission] |
Employer's Statement of Wage Earnings Preceding Date of Accident | Employer | Workers' Compensation Board | Within 10 days of request by the Board. |
| C-250 (3/07) | Notice of Claim for Reimbursement Out of Special Disability Fund Under Section 15-8 | Insurance Carrier/Board-approved Self-Insurer | Original and one copy to WCB Finance Office, 20 Park St. Room 301, Albany NY 12207 A check for $250, payable to "Special Disability Fund", must be included with each claim. |
Prior to final determination that disability is permanent, but in no case more than 104 weeks after the date of disability or death, or 52 weeks after the date that a claim for compensation is filed with the chair, whichever is later. |
| C-251 (11/01) Form must be printed on yellow paper. |
Carrier's Request for Reimbursement of Compensation Payments Under Section 15-8 | Insurance Carrier/Board-approved self-insurer | Local office of Special Funds Conservation Committee; copy to Finance Office, WCB, 20 Park Street, Albany NY 12207 | For twenty-six week periods, if possible. |
| C-251.1 (11/01) Form must be printed on pink paper |
Carrier's Request for Reimbursement of Medical Expenses Under Section 15-8 | Insurance Carrier/Board-approved self-insurer | Local office of Special Funds Conservation Committee; copy to Finance Office, WCB, 20 Park Street, Albany NY 12207 | For twenty-six week periods, if possible. |
| C-251.2 (11/01) Form must be printed on blue paper |
Carrier's Request for Reimbursement of Compensation Payments Under Section 14(6) Concurrent Employment | Insurance Carrier/Board-approved self-insurer | Local office of Special Funds Conservation Committee; copy to Finance Office, WCB, 20 Park Street, Albany NY 12207 | For twenty-six week periods, if possible. |
| C-251.3 (8/09) | Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) and Section 15(8) | Insurance Carrier/Board-approved self-insurer | Original to Workers' Compensation Board (to be filed in case); One copy to WCB Finance Office, 20 Park St. Albany NY 12207; retain one copy for your records. | Notice must be filed prior to the decision making an award. |
| 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-300.5 (7/97) | 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-430S (8/09) | Statement of Rights (WCL) | Insurance Carrier/Board-approved self-insurer | Sent to injured employee. | Within 14 days of receipt of Form C-2 from employer, or with initial benefit check, whichever is earlier. |
| C-669 (8/09) Paper Version [C-669 On-line Submission] |
Notice to Chair of Carrier's Action on Claim for Benefits | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, with copy to claimant and his/her representative. | IF PAYMENT HAS BEGUN: on or before 18th day after disability, or within 10 days after employer first had knowledge of injury, whichever is greater. IF PAYMENT HAS NOT BEGUN: no later than 25 days after the Board has mailed a Notice of Indexing. |
| CB-8 (4/01) (obsolete) |
Replaced by Form RFA-2 | |||
| GSI-105.2 (2/02) | Certificate of Participation in Workers' Compensation Group Board-approved self-insurance | Employers participating in group self-insurance for workers' compensation | Filed with the government agency issuing a permit, license or contract. The GSI-105.2 must be completed by the group self-insurance administrator. | Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their group self-insurance administrator. For further information contact the Board's Self-Insurance Office at (518) 402-0247. |
| MD-3 (12/09) | Carrier/Board-approved self-insured employer's Objection to Attending Doctor's Request for Medical Authorization Determination | Carrier/Board-approved self-insured employer | Workers' Compensation Board | Within ten (10) days after filing of Form MD-1, Request for Medical Authorization Determination |
| OC-400.5 (3/09) | Attorney/ Representative's Certification of Form C-3 or C-7 | 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 Form C-7 has been filed without your written certification, OC-400.5 must be filed before you may appear on behalf of the carrier. |
| OC-403.1 (09/07) | Initial Application for License | This form is to be completed by two senior officers of the corporation and the qualifying officer. | New Licenses | |
| OC-403.1R (09/07) | Renewal Application for License | This form is to be completed by two senior officers of the corporation and the qualifying officer. | License Renewal | |
| OC-403.2 (09/07) | Initial Application by Employee of Licensee | This form is to be completed by the qualifying officer. | New Licenses | |
| OC-403.2R (09/07) | Renewal Application by Employee of Licensee | This form is to be completed by the qualifying officer. | License Renewal | |
| OC-403.3 (09/07) | Stockholder of Corporation Applying for License (New and Renewal) | This form is to be completed by each principal stockholder owning at least 20 percent of the corporation's stock. | New Licenses and License Renewal | |
| OC-407 (3/97) | Self-Insurer’s Representative’s Bond | Third Party Administrators | Workers’ Compensation Board, Licensing Bureau | At time of initial application or renewal |
| PH-16.2 (8/09) Paper Version [PH-16.2 On-line 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. | Ten days before scheduled pre-hearing conference for controverted (C-7) cases. |
| R (8/05) | Carrier's Report on Rehabilitation | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to claimant and his/her 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 (11/09) | Cover Sheet - 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 (11/09) | Cover Sheet - 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 (11/09) | Cover Sheet – Application for 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 (11/09) | Cover Sheet – Rebuttal of Application for 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. |
| RB-679 (11/01) (obsolete) |
Replaced by Form RFA-2 | |||
| RFA-2 (8/09) Paper Version [RFA-2 On-line Submission] |
Carrier's/Employer's Request for Further Action | Insurance Carrier or Board-approved self-insured employer | Workers' Compensation Board, with copies to claimant and his/her representative, if any. | The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORMS C-89.3, C-22B, CB-8 AND RB-679. |
| SI-12 (7/09) | Affidavit Certifying That Compensation Has Been Secured | Employers with Board-approved self-insurance for workers' compensation | Filed with the government agency issuing a permit, license or contract. The SI-12 must be completed by the Board's Self-Insurance Office and approved by the Board's Secretary. | Upon obtaining a permit, license or contract from a government agency. Board-approved self-insurers must obtain this form from Board's Self-Insurance Office. (518) 402-0247 |
| 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 e-mail the Board's Forms Department.
