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, DB-120, DB-120.1 and DB-155 are not available on this site. Contact your insurance carrier or licensed NYS insurance agent for these forms..
C-4 Medical Billing Forms
All versions of the C-4 medical billing forms (except the C-4.3) were replaced by the required submission of the CMS-1500 form on July 1, 2022. Learn more about the CMS-1500 Initiative
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."
RFA-2 and other Board form updates – December 2023
The Request for Further Action by Insurer/Employer (Form RFA-2) has been modified to better align with the process for resolving payer denials of the Workers' Compensation Board's New York Medical Treatment Guidelines (MTGs) Variance and MTG Special Services Prior Authorization Requests (PARs).
Additionally, the Board will no longer be accepting older versions of several forms. Read more in a notification dated December 4, 2023.
Original Signature Requirement
Common Workers' Compensation Board Forms
| Form Number/ Version Date |
Form Title | Who Files | Where to File | When to File |
|---|---|---|---|---|
| A-9 (11/21) | Notice that You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim is Disallowed, or if Agreement Pursuant to WCL §32 is Approved | Employee | File with Health Provider | Health providers are permitted to obtain the claimant's agreement to pay usual and customary fees in the event claim is not prosecuted or is disallowed. Form should be retained by doctor after it is completed and signed. |
| ADR-1 (6/22) | Alternative Dispute Resolution Program Report of Injury | Employers Participating in the Alternative Dispute Resolution Program | Workers' Compensation Board |
Within 10 days of a work-related injury or illness.
Note: Print form on WHITE paper, not green. |
| ADR-1.1 (1/11) | Alternative Dispute Resolution Program: Modification of Previous Report | Employers Participating in the Alternative Dispute Resolution Program | Workers' Compensation Board | Whenever it is necessary to modify, clarify or update information reported on any previously filed ADR form. |
| ADR-2 (1/11) | Alternative Dispute Resolution Program Final Disposition or Settlement of Claim | Employers Participating in the Alternative Dispute Resolution Program | Workers' Compensation Board |
Within 30 days of final disposition or settlement of the claim.
Note: Print form on WHITE paper, not green. |
| AFF-1 (1/24) | Affidavit For Death Benefits | Claimant (see when to file) | Workers' Compensation Board | This affidavit is to be used by a surviving spouse or the dependent child(ren) of the deceased; by dependent brothers/sisters/grandchildren; by dependent parents/grandparents. It can also be used by the non-dependent parents or the estate of the deceased where there is no surviving spouse or other dependents. |
|
C-2F (9/23) Paper Version
[C-2F Instructions] |
Employer's Report of Work-Related Injury/Illness | Employer (contact your insurer who can provide advice for the best method to report the information.) | Workers' Compensation Board, copy to insurer. | 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-3 (6/22) Paper Version [C-3 Online Submission] |
Employee Claim | Employee | Workers' Compensation Board, in the event of on-the-job injury or illness. | Within two years of accident, or within two years after employee knew or should have known that injury or illness was related to employment. If your injury was the result of the use or operation of a licensed motor vehicle: If you filed a Department of Motor Vehicles Form MV-104 (Report of Motor Vehicle Accident), please submit a copy along with the C-3. This will expedite the process for you to receive potential benefits. |
|
C-3.1 (3/04)
C-3.1S (Spanish version) on reverse |
Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider | Employee | Completed by injured employee when employer who is not part of a PPO or ADR program wishes to recommend a network or provider to such employee for treatment purposes. The form is maintained by employer and is not submitted to the Board. | The consent shall not be executed prior to the occurrence of employee's work-related injury or illness, but must be executed prior to an employer, who is not part of a PPO or ADR program, recommending a network or provider to an injured employee for treatment purposes. |
| C-3.3 (12/09) | Limited Release of Health Information (HIPAA) | Claimant | Workers' Compensation Board | If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current Claim, fill out this form. |
|
C-4 (8/20) Paper Version [C-4 Online Submission] As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R – Rochester Medical Reporting Information on the CMS-1500 Initiative |
Doctor's Initial Report |
|
Workers' Compensation Board, insurer, injured employee or employee's representative |
This form is filed within 48 hours of first treatment.
To report continued treatment, use Form C-4.2. To report permanent impairment use Form C-4.3. |
|
C-4.1 (9/08)
As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R – Rochester Medical Reporting Information on the CMS-1500 Initiative |
Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4 | Health Care Provider | See Form C-4. This form must be attached to and filed with Form C-4. (May also be used with Forms C-4.2, C-4.3, C-5, PS-4 and OT/PT-4) | See Form C-4. Use as continuation sheet when more than six dates of service must be shown in the billing portion of Form C-4. (May also be used with Forms C-4.2, C-4.3, C-5, PS-4 and OT/PT-4) |
|
C-4.2 (10/15) Paper Version [C-4.2 Online Submission] As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R – Rochester Medical Reporting Information on the CMS-1500 Initiative |
Doctor's Progress Report |
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Workers' Compensation Board, insurer, injured employee or employee's representative | This form is used for the 15 day report after first treatment, and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart. To report the first time you treated claimant use Form C-4. To report permanent impairment use Form C-4.3. |
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C-4.3 (5/22) Paper Version [C-4.3 Online Submission] |
Doctor’s Report of MMI/Permanent Impairment |
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Workers’ Compensation Board, insurer, injured employee or employee's representative | Use this form (1) when rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers’ Compensation Board to render a decision of MMI and/or permanent impairment. |
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C-4 AMR (10/15) Paper Version [EC-4 AMR Online Submission] As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R – Rochester Medical Reporting Information on the CMS-1500 Initiative |
Ancillary Medical Report | Provider Other than the Attending Provider | Workers' Compensation Board, insurer, injured employee or employee's representative | As soon as possible after ancillary treatment or services (such as radiology, pathology or diagnostic services) are rendered. |
|
C-4 AUTH (7/18)
As of 5/2/22, this form is no longer being accepted by the Board. All requests are to be submitted using OnBoard. |
Attending Doctor's Request for Authorization and Carrier's Response | Health Care Provider | Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. If the patient is represented by an attorney or licensed representative send a copy to such legal representative. If the patient is not represented, a copy must be sent to the patient. | This form is used to confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation. |
|
EC-4NARR (10/15) Online Submission As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R – Rochester Medical Reporting Information on the CMS-1500 Initiative |
Doctor's Narrative Report | Health Care Provider | Workers' Compensation Board, insurer, injured employee or employee's representative |
Use this form to report first treatment; for the 15 day report after first treatment; and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart. services. To report permanent impairment use Form C-4.3.
Use this form only if attaching a detailed narrative report. See Attachment Requirements for topics that must be addressed in the narrative attachment. |
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C-5 (10/15)
As of 7/1/22, CMS-1500 should be used. Information on the CMS-1500 Initiative |
Attending Ophthalmologist's Report | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or employee's representative |
48 hour initial report, within 48 hours of first treatment.
15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
|
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 employee's 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. |
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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 employee's 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 insurer 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. |
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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 |
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C-32.1 (4/24)
As of October 19, 2024, 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. |
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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. |
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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. |
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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-35 (4/17) | Extreme Hardship Redetermination Request Section 35(3) of the Workers' Compensation Law | Injured Worker | Workers' Compensation Board | When an injured worker is requesting a redetermination due to an extreme hardship as described in Section 35(3) of the Workers' Compensation Law and has been classified with a permanent partial disability with a loss of wage earning capacity of greater than 75% and capped benefits will expire within one year. |
| C-62 (1/11) | Claim for Compensation in Death Case | Claimant (The claimant is the surviving spouse, child or dependent of the deceased. See the reverse of the form for details on who may file a claim in a death case.) | Workers' Compensation Board in the event of on-the-job death. | Within two years of accidental death. |
| C-64 (1/11) | Proof of Death by Physician Last in Attendance on Deceased | Health Provider | Workers' Compensation Board and insurance carrier/Board-approved self-insurer | Upon death of claimant, or when requested by WCB |
| C-65 (1/24) | Proof of Burial and Funeral Expenses by Undertaker | Undertaker | Workers' Compensation Board | When requested by WCB |
| C-72.1 (1/12) | Record of Percentage Hearing Loss | Health Provider | Workers' Compensation Board, insurer, injured employee or employee's representative. | Upon completion of audiometric test battery. |
| C-100.2 (1/24) | Affidavit for License to Operate an X-Ray Bureau or Laboratory | Bureaus and Laboratories engaged in X-ray diagnosis or treatment. | NYS Workers' Compensation Board Medical Director's Office 150 Broadway, Suite 195 Menands, NY 12204 provider@wcb.ny.gov Fax: 518-408-5599 | Upon registration (or renewal) with the NYS Department of Health (see 10 NYCRR 16.50) |
| 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’ compensation 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.
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| C-105.3 (5/04) | Notice of Election of an Incorporated Religious, Charitable, Educational, or U.S. War Veterans Organization to Bring Executive Officers under the Coverage of the new York Workers' Compensation law. | Executive Officers | Filed with the insurer. | File with the insurer. |
| C-105.4 (11/96) | Revocation of election of an incorporated religious, charitable, educational, or U.S. War Veterans organization to bring executive officers under the coverage of the New York Workers' Compensation Law | Executive Officers | Filed with the insurer. | File with the insurer. |
| 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 (1/24) | 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-105.31 (1/04) | Notice of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL | Municipal Corporation or Political Subdivision | File with insurer. | File with insurer. |
| C-105.32 (4/04) | Notice of Election of a Partnership, Limited Liability Partnership, Professional Limited Liability Partnership, Limited Liability Company, Professional Limited Liability Company or Sole Proprietorship to Bring Partners, Members or Self-Employed Persons Under the Coverage of the New York State Workers' Compensation Law | Partnership or Sole Proprietorship | File with insurer. | File with insurer. |
| C-105.41 (1/04) | Revocation of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL | Municipal Corporation or Political Subdivision | File with insurer, copy to Chair, WCB, attn: Compliance Bureau 328 State Street, Schenectady, NY 12305-2318, and to each officer named on form. |
Revocation is effective 30 days after date filed with WCB and insurer. |
| C-105.51 (1/04) | Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage | Sole Shareholder Officer or Two Executive Officers of a corporation required to have workers' compensation coverage | File with insurer. Board-approved self-insured employers file with the WCB Self-Insurance Office. Board-approved group self-insured's file with the WCB Self-Insurance Office and also with your Group Administrator. | As soon as the corporation wishes to exclude the sole shareholder-officer, or one of the two or both executive officers-shareholders of the corporation from workers' compensation coverage. |
| C-105.52 (1/04) | Notice of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage | Not-for-Profit Corporation or Unincorporated Association | File with insurance carrier. | Unsalaried executive officer is deemed included in insurance contract until election to exclude is filed. |
| C-105.53 (1/04) | Revocation of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage | Not-for-Profit Corporation or Unincorporated Association | File with insurer, copy to Chair, WCB, attn: Compliance Bureau, 328 State Street, Schenectady, NY 12305-2318. |
Revocation is effective 30 days after the date filed by the corporation or association with the insurer and the WCB. |
| C-105.54 (3/99) | Notice of Election to Bring Sheltered Workshop Participants Under Coverage of WCL | Office or agency operating sheltered workshop | File with insurer, copy to Chair, WCB, attn: Compliance Bureau, 328 State Street, Schenectady, NY 12305-2318. |
File with insurer. |
| C-105.55 (1/04) | Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage | Sole Shareholder Officer or Two Executive Officers of a corporation required to have workers' compensation coverage | File with insurer, copy to Chair, WCB, attn: Compliance Bureau, 328 State Street, Schenectady, NY 12305-2318. If Board-approved self-insured employer, to WCB only. |
Upon deciding to revoke election to exclude officer(s) from coverage. |
| C-107 | Employer's Request for Reimbursement (NY State Insurance Fund) | This is a New York State Insurance Fund form. If you are an employer insured by the NY State Insurance Fund, contact your local State Insurance Fund office for this form, or call toll-free (888) 875-5790. | ||
| C-121 (1/11) | Claim for Compensation and Notice of Commencement of Third-Party Action | Employee | Workers' Compensation Board, the employer and insurer. | Within 30 days after third-party action has been commenced. |
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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. |
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C-251 (10/22) (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. |
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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-257 (11/21) | Claimant's Record of Medical and Travel Expenses and Request for Reimbursement | Claimant | Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. | As needed. Include copies of all receipts and bills, if possible. |
| C-258 (5/19) | Claimant's Record of Job Search Efforts/Contacts | Claimants who are partially disabled and are not employed or working, except a claimant who was entitled to benefits at the time they were classified with a permanent partial disability. | This form and all documents supporting your job search efforts must be submitted to the Board in advance of your hearing, or brought with you on the date of your hearing and will be collected by the WC Law Judge. Please refer to the detailed instructions on page two of this form for where/when to file this form. |
This form is used to record efforts made to search for work within the claimant's medical restrictions and with the assistance of an agency or employment counselor. Please refer to the detailed instructions on page two of this form for where/when to file this form. |
| C-258.1 (7/17) | Claimant's Record of Independent Job Search Efforts | Claimants who are partially disabled and are not employed or working, except a claimant who was entitled to benefits at the time they were classified with a permanent partial disability. | This form and all documents supporting your job search efforts must be submitted to the Board in advance of your hearing, or brought with you on the date of your hearing and will be collected by the WC Law Judge. Please refer to the detailed instructions on page two of this form for where/when to file this form. |
This form is used to record efforts made to search for work within the claimant's physical restrictions through an independent job search.
Please refer to the detailed instructions on page two of this form for where/when to file this form. |
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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. |
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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. |
| C-500 (6/24) | Disability Benefits, Rates and Awards | Maximum and Minimum Award Rates From 7/1/58 to Present | ||
| C-500.1 (6/16) | Death Benefits, Rates and Awards | Use Form C-500.1 to determine death benefits in claims filed under the Workers’ Compensation Law, the Volunteer Firefighter Benefits Law, and the Volunteer Ambulance Worker Benefits Law. | ||
| C-DB-22 | Employer's Statement (for Form DB-450) (NY State Insurance Fund) |
This is a New York State Insurance Fund form.
The State Insurance Fund has pre-printed Form DB-450 with the Employer's Statement on the reverse. |
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| CE-200 (12/08) | Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage | Applicants for permits, licenses or contracts from State, county or municipal agencies in New York State that are not required to carry NYS workers' compensation and/or disability benefits insurance coverage. | Please file with the government agency that is issuing the permit, license or contract. (Examples: The New York City Department of Buildings or the New York State Department of Health) | These exemption forms can ONLY be used to attest to a government entity that an applicant requesting a permit, license or contract from that government entity is not required to carry NYS workers' compensation and/or disability benefits insurance. Apply online at New York Business Express . |
| DB-26 (10/17) | Notice of Election of Political Subdivision for Self-Insurance-Disability and Paid Family Leave Benefits Law | Political subdivision, ambulance or fire district | Notice to the Chair that a political subdivision, ambulance or fire district has elected to secure Disability and/or Paid Family Leave benefits as a self-insurer | When appropriate |
| DB-118 (10/17) | Employer's Statement for the Purpose of Terminating Status as a Covered Employer | Employer | Mail to Workers' Compensation Board, Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200 | When terminating status as a covered employer. |
| DB-120 (11/17) | Notice of Compliance - New York State Disability Benefits | Employers insured for disability benefits through an insurance carrier or Board-approved self-insurance. | This form is not filed. It is completed by the licensed insurance carrier or self-insured administrator with identifying insurance information and then displayed by the employer in the workplace. | Upon securing of disability benefits 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. |
| DB-120.1 (12/21) | Certificate of Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law | Employers | Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The DB-120.1 must be completed by either the NYS statutory disability benefits insurance carrier, or a licensed NYS insurance agent of that carrier. | Employers must obtain this form from either their NYS statutory disability benefits insurance carrier or a licensed NYS insurance agent of that carrier. |
| DB-120.2 (10/17) | Certificate of Participation in Disability or Disability and Paid Family Leave Benefits Group Self-Insurance | Employers | Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The DB-120.2 must be completed by the Plan Administrator or authorized representative. | Employers must obtain this form from their administrator. The administrator should contact Certificates@wcb.ny.gov to get a copy of the form they can distribute to their members. |
| DB-120.10 (1/09) | Gummed Label for Use with Form DB-120 Upon Renewal of Policy | Not Filed | Upon renewal of a policy, employers receive this gummed label from their disability benefits insurer. Employers then place the DB-120.10 label over the expired policy information on the bottom of Form DB-120. | Upon renewal of a disability benefits insurance policy, the insurer may issue this label with updated policy information in lieu of issuing an entire new Form DB-120 poster, as long as the current version of Form DB-120 is already being used. Employers must obtain this form from their insurer. Insurers may contact the Board's Forms Department. |
| DB-125 (5/19) | Employer Identification Information, Disability Benefits Law | Employer | Given to employees to provide information to facilitate filing of DB claims. | Issued to employees upon separation from employment. |
| DB-130 (1/24) | Employee's Statement of Exempt Status | Employee |
One notarized copy to:
Workers' Compensation Board Disability Benefits Bureau PO Box 9029 Endicott, NY 13761-9029 And One notarized copy to your employer |
Any employee receiving or entitled to receive Social Security retirement benefits may submit this form at any time to waive any and all benefits under the Disability and Paid Family Leave Benefits Law |
| DB-135 (09/19) | Employer’s Application for Voluntary Coverage (No Employee Contribution) | Employer | Workers' Compensation Board, Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200 or email to PAU@wcb.ny.gov | To voluntarily cover employees for whom DB is not required under the Law with no employee contributions to the cost of the coverage. |
| DB-136 (09/19) | Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (Employee Contribution) | Employer | Workers' Compensation Board, Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200 or PAU@wcb.ny.gov | To voluntarily cover employees for whom DB is not required under the Law with employee contributions to the cost of the coverage. |
| DB-150 (1/24) | Application for Self-Insurance-Disability and Paid Family Leave Benefits | Employer | Filed when applying for self-insurance under the Disability and Paid Family Leave Benefits Law | No filing deadline |
| DB-155 (9/16) | Certificate of Self-Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law | Employers with Board-approved self-insurance for disability benefits | Filed with the government agency issuing a permit, license or contract. The DB-155 must be completed by the Board's Self-Insurance Office. | Upon obtaining a permit, license or contract from a government agency. Board-approved self-insured employers must obtain this form from the Board's Self-Insurance Office by emailing selfinsurance@wcb.ny.gov |
| DB-212.3 (10/17) | Notice of Election of a Corporation which is required to have Disability and Paid Family Leave Benefits Coverage for its Employees under the Disability and Paid Family Leave Law to Exclude the Sole Shareholder-Officer or One of Two Shareholder-Officers or Shareholder-Officers of the Corporation from Such Coverage | Sole Shareholder Officer(s) of a Corporation | File with insurance carrier. Board-approved self-insured employers file with WCB Self-Insurance Office. Board-approved group self-insured's file with the WCB Self-Insurance Office and also with your group administrator. | Officers are deemed included in insurance contract until election to exclude is filed. |
| DB-212.5 (10/17) | Notice of Election to Voluntarily Exclude Spouse from Coverage Pursuant to Section 212, Subdivision 5 of the NYS Disability and Paid Family Leave Benefits Law | Employer | File with Insurance carrier or, if Board-approved self-insurer (or no carrier and spouse is only employee), with the WCB. | File when election is made to exclude spouse from coverage. |
| DB-271S (12/23) | Statement of Rights (DBL) | Insurance Carrier/Board-approved self-insurer | Issued by employer to disabled employee. | When covered employee is absent from work due to disability for more than 7 consecutive days, form must be issued within 5 business days thereafter; or within 5 days after employer knows or should know that absence is due to disability, whichever is greater. |
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DB-450 (10/23) |
Notice and Proof of Claim for Disability Benefits | Claimant |
If you became sick or disabled while employed or you became sick or disabled within four (4) weeks after termination of employment, file with your employer or its insurer.
If you became sick or disabled after having been unemployed for more than four (4) weeks, file with: Workers' Compensation Board Disability Benefits Bureau PO Box 9029 Endicott, NY 13761-9029 |
File no later than 30 days after becoming sick or disabled. |
| DB-450.1 (9/17) | Claimant's Statement Regarding No Fault or Personal Injury | Claimant |
Workers' Compensation Board Disability Benefits Bureau PO Box 9029 Endicott, NY 13761-9029 |
File with Form DB-450. |
| DB-451 (5/19)
The Board will only accept the current version of this form. |
Notice of Total or Partial Rejection of Claim for Disability Benefits | Insurance Carrier/Board-approved self-insurer | Send one copy to claimant. | Within 45 days of receipt of claim. Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form. |
| DB-470 (6/22)
The Board will only accept the current version of this form. | Preliminary/Final Claim for Reimbursement of Benefits Paid Under DBL | Disability Benefits Insurer | Workers' Compensation Board, copies to workers' compensation insurer, claimant and claimant's representative. | Prior to award of workers' compensation benefits. Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form. |
| DB-800 (1/24) | Self-Insured Employers providing Disability and/or Paid Family Leave Benefits offering a shorter waiting period or a longer duration than statute requires (Application and Agreement) | Self-Insured Employers providing Disability and/or Paid Family Leave Benefits offering a shorter waiting period or a longer duration than statute requires | Email to PAU@wcb.ny.gov or mail to Workers’ Compensation Board, Plans Acceptance Unit, P.O. Box 5200, Binghamton, NY 13902-5200 | When a Self-Insured Employer wants to provide Disability and/or Paid Family Leave Benefits to a Class of employees and/or offers a shorter waiting period, or a longer duration than statue requires. |
| DB-801 (1/24) | Plan of an Association of Employers or Employees, Union or Trustees Providing Disability and/ or Paid Family Leave Benefits (Application and Agreement) | Plan Administrator for Association of Employers or Employees, Union of Trustees files. | Email to PAU@wcb.ny.gov or mail to Workers’ Compensation Board, Plans Acceptance Unit, P.O. Box 5200, Binghamton, NY 13902-5200 | When an Association of Employers or Employees, Union or Trustees wants to become a Plan that provides Disability and/or Paid Family Leave Benefits. |
| DB-802 (1/24) | Application to have Association, Union or Trustees Plan Accepted/Terminated as Employer's Plan | Employer files form after Association, Union or Trustee has signed it. | Email to PAU@wcb.ny.gov or mail to Workers' Compensation Board, Plans Acceptance Unit, P. O. Box 5200, Binghamton, NY 13902-5200 | When an employer becomes a participant in a plan administered by an association, union or trust. |
| DB-820/829 (9/17) | Certificate/Cancellation of Insurance | Carriers insuring employers for disability and paid family leave benefits through Plan Coverage, Enriched Coverage, or Class Coverage. | ONLY insurers providing Plan Coverage, Enriched Coverage, or Class Coverage file this paper form with the Disability Benefits Office at the Workers' Compensation Board to show proof of statutory disability and paid family leave benefits coverage. | Upon writing a disability and paid family leave benefits policy for Plan Coverage, Enriched Coverage, or Class Coverage. Carriers may contact the Board's Forms Department to obtain this form. |
| DB-820.1 (3/18) | Supplement to Certificate of Insurance | Carriers insuring employers for disability and paid family leave benefits through Plan Coverage, Enriched Coverage, or Class Coverage | File with Form DB-820/829. | Attach to and make part of Form DB-820/829. |
| DB-820.3 (10/17) | Certificate of Insurance on behalf of Association, Union or Trustees of Plan benefits. | Carriers insuring employers for Disability and Paid Family Leave benefits through Plan Coverage. | Carriers are to submit this form to the Board on behalf of the Association, Union or Trust. The form requires a signature from the insurance carrier and an authorized representative from the Association, Union or Trust. Must be filed with the DB-801 initial application. | Upon writing a Disability and Paid Family Leave benefits policy for Plan Coverage. Carriers may contact the Board's Forms Department to obtain this form. |
| DB-829.3 (10/17) | Notice of Cancellation for Association, Union or Trustees of Plan benefits. | Carriers insuring employers for Disability and Paid Family Leave benefits through Plan Coverage. | Carriers are to submit this form to the Board on behalf of the Association, Union or Trust. The form requires a signature from the insurance carrier and an authorized representative from the Association, Union or Trust. | Carriers may contact the Board's Forms Department to obtain this form. |
| DB-850 (10/17) | Application for Acceptance of Insurance Form Under Section 360.1(b)(1) NYCRR | Insurance Carrier | Email to PAU@wcb.ny.gov or mail to Workers' Compensation Board, Plans Acceptance Unit, P. O. Box 5200, Binghamton, NY 13902-5200 | File when new forms needs approval. |
| DB-DEN (10/23) | Notice of Denial of Claim for Disability Benefits | Insurance Carrier/Board-approved self-insurer | Send one copy to claimant | Within 18 days of the first day of disability or receipt of the request for disability benefits unless DB-451 is issued in this timeframe. Carriers and Board-approved Self-Insurers may contact the Board's Forms Department. |
| DC-120 (2/24) | Discharge or Discrimination Complaint | Employee who is alleging that an employer has discharged or discriminated against them because they claimed or attempted to claim compensation |
New York State Workers' Compensation Board Disability and Discrimination Unit PO Box 9029 Endicott, NY 13761-9029 |
Any complaint alleging an unlawful discriminatory practice must be filed within two years of the commission of such practice. |
| 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. |
| DD-2 (9/05) | Biannual Recertification to Entitlement to Benefits | A claimant who is having benefit checks directly deposited in a financial institution. | Insurance Carrier or Board-approved self-insured employer. DO NOT FILE WITH THE WORKERS' COMPENSATION BOARD. |
Every six months, upon receipt of the form from the carrier/Board-approved self-insured employer. |
| 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 employee's 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 insurer contracts with a DTN
To medical provider when insurer contracts with a DTN, or at time of first medical bill. |
| Electronic Attachment (5/01) | Attachment to Form_______ (may accompany any Board form.) | All parties may use this form. | Staple to Board form being filed and submit together according to the instructions given on the primary form. | For your convenience, if additional space is needed to complete an item or items on a Board form, you may use this attachment, being sure to fill in all identifying information at the top of the form, and staple it to the form being submitted. |
| Evidence Cover Letter (9/22) | Evidence Cover Letter | Any case party of interest | NYS Workers' Compensation Board Centralized Mailing Address P.O. Box 5205 Binghamton, NY 13902-5205 |
Submission of video evidence |
| FCE-4 (1/11) | Practitioner's Report of Functional Capacity Evaluation | Physical or Occupational Therapist | Workers' Compensation Board, insurer, injured employee or employee's representative | See reverse of form for complete filing indications and requirements. |
| HIMP-1 (7/18) | New York State Workers’ Compensation Board Health Insurance Matching Program | Private Health Insurer/Health Benefits Plan | Insurance carrier or Board-approved self-insurer | When claiming reimbursement for health benefits paid in a workers' compensation case. |
| HIPAA-1 (12-03) | Claimant's Authorization to Disclose Health Information (Pursuant to HIPAA). Note: the HIPAA-1 form is used by payers to obtain medical records from covered entities under HIPAA. Claimants looking to authorize disclosure of their Workers’ Compensation Records should use the OC-110a form. |
Claimant | Give the completed form to your doctor, who will keep it with your records. THIS FORM SHOULD NOT BE FILED WITH THE WORKERS' COMPENSATION BOARD. | Click here for Workers' Compensation Guidelines on HIPAA Restrictions and Medical Records |
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HP-1.0 (11/24)
As of 11/24, if an HP-1 is submitted for Arbitration, the form ID listed in the case folder and on the Request for Decision on Unpaid Medical Bill(s) PDF will be HP-1.0 ARB to identify the type of billing dispute. |
Request for Decision on Unpaid Medical Bill(s) | Health Provider and Medical Suppliers | Must be submitted online using OnBoard | Form HP-1.0 may not be submitted if less than 45 days have elapsed from the submission date of the bill or if you have received a timely Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) from the claim administrator and the legal objection(s) related to the bill have not yet been resolved. |
| HP-4 (4/05) | Notice to Chair: Health Provider's and Insurer's Withdrawal of Request for Arbitration | Health Provider or Insurance Carrier/Board-approved self-insurer | Medical Director's Office, Riverview Center, 150 Broadway - Suite 195, Menands, NY 12204 | See reverse of form for filing conditions |
| HP-J1 (1/24) | Provider's Request for Judgment of Award (WCL 54-b) | Authorized Workers' Compensation Health Provider | Workers' Compensation Board Disputed Medical Bills Unit, 328 State Street, Schenectady, NY 12305 | For awards/decisions made on or after March 13, 2007. Upon issuance of an administrative award and/or arbitration decision you must wait at least 30 days before requesting consent for judgment. To avoid the complications of filing unnecessary requests, waiting 60 days is recommended. The 60 day time period will allow for insurers' billing/payment cycles. |
| IME-3 (7/14) | Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination | Independent Examiners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board |
To report request for information - file within 10 days of receipt of the request.
To report response to a request for information - file within 10 days of submission of response. See form for complete instructions. |
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IME-4 (5/18)
Implementation of Forms Associated with SLU Evaluations |
Independent Examiner's Report of Independent Medical Examination | Independent Examiners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board; insurance carrier or Board-approved self-insured employer; claimant's attending physician or other attending practitioner; the claimant's representative, if any, and the claimant. | Report shall be filed with the Board and provided to all parties on the same day in the same manner. |
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IME-4.3A (5/18)
Implementation of Forms Associated with SLU Evaluations |
Attachment for Report of Independent Medical Examination Scheduled Loss of Use | Independent Examiners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board; insurance carrier or Board-approved self-insured employer; claimant's attending physician or other attending practitioner; the claimant's representative, if any, and the claimant. | File this form as an attachment to Independent Examiner's Report of Independent Medical Examination, IME-4, for Scheduled Loss of Use. |
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IME-4.3B (5/18)
Implementation of Forms Associated with SLU Evaluations |
Attachment for Report of Independent Medical Examination Non-Scheduled Permanent Partial Disability | Independent Examiners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board; insurance carrier or Board-approved self-insured employer; claimant's attending physician or other attending practitioner; the claimant's representative, if any, and the claimant. | File this form as an attachment to Independent Examiner's Report of Independent Medical Examination, IME-4, for Non-Scheduled Permanent Partial Disability. |
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IME-5 (5/18)
Implementation of Forms Associated with SLU Evaluations |
Claimant's Notice of Independent Medical Examination | Claim Administrator/Insurer | Mail to the claimant, and Workers' Compensation Board. | Claimant must receive notice by mail at least seven business days prior to the scheduled examination. |
| IME-7 (1/24) | Statement of Registration (Sec. 13n -WCL) | Entities deriving income from independent medical examinations | Medical Director's Office, Riverview Center, 150 Broadway - Suite 195, Menands, NY 12204 | A completed registration form and receipt of a registration number assigned by the Board are required for all IME entities conducting business on or after March 20, 2001. File as soon as possible. Statement must include the notarized signature of an officer of the company, and must be accompanied by a $250 registration fee. |
| IS-1 (2/13) | Physician's Application for Designation as an Impartial Specialist | Physician seeking Impartial Specialist designation | Workers' Compensation Board, Medical Director's Office | When applying for designation as an Impartial Specialist |
| IS-1R (2/13) | Physician’s Application for Renewal of Designation as an Impartial Specialist | Physician seeking renewal of Impartial Specialist designation | Workers' Compensation Board, Medical Director's Office | 60 days prior to the end of your designation term. |
| IS-4 (2/13) | Physician’s Report of Impartial Specialist Examination or Impartial Specialist Record Review | Physician | Workers' Compensation Board | Within 20 days of the examination or within 25 days of receipt of records. |
| Language Access Comment Form | Form is for both internal and external use. | Workers' Compensation Board | New York State’s policy is to provide language access to public services and programs. If you feel that we have not provided you with adequate interpretation services or have denied you an available translated document, please ask for our complaint form to give us your feedback. | |
| MG-1 (4/18)
As of 5/2/22, this form is no longer being accepted by the Board. All requests are to be submitted using OnBoard. |
Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response | Health Care Provider | Workers' Compensation Board and Insurer | Request confirmation from the Insurer that the procedure or test is based on a correct application of the Medical Treatment Guidelines. |
| MG-2 (4/18)
As of 5/2/22, this form is no longer being accepted by the Board. All requests are to be submitted using OnBoard. |
Attending Doctor's Request for Approval of Variance and Carrier's Response |
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Workers' Compensation Board, insurer, injured employee and employee's representative | To request testing or treatment that is outside or exceeds the Medical Treatment Guidelines. |
| MR-4 (1/11) | Impartial Specialist's Report of Medical Records Review | Impartial Specialist | Workers' Compensation Board | When the Board has requested an Impartial Specialist Medical Records review on procedures that require pre-authorization under Medical Treatment Guidelines. |
| OC-110A (12/17) | Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) | Claimant | Workers' Compensation Board | Claimant must submit form with original signature in order to allow release of their records to parties not otherwise authorized to receive them. |
| 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 (1/23) | Notice of Retainer and Substitution | Attorney/Licensed Representative | Workers' Compensation Board, copy to all claimant's health providers, copy to insurance carrier/self-insured employer. |
Immediately upon being retained. An R number is required. Request R Number |
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OC-400.1 (1/23)
The Board will only accept the current version of this form. New Fee Application Desk Aid |
Application for a Fee by Claimant’s Attorney or Licensed Representative | Attorney/Licensed Representative | Workers’ Compensation Board, copy to the claimant. |
When fee of more than $1,000 is requested.
If claimant not present, they must be advised of fee request, using this form, 10 days prior to awarding of fee. |
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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.
Insurer'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 insurer. |
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OC-400.17 (8/20)
The Board will only accept the current version of this form. |
Attorney/Licensed Representative Request to Withdraw from Representation | Attorney/Licensed Representative | Workers' Compensation Board, copy to all other parties of interest. | Once completed, this form is to be filed immediately. |
| OC-401.1R (1/24) | Renewal Application for License to Appear on Behalf of Claimant | This form is to be completed by the individual renewing license. | Workers' Compensation Board, Licensing Bureau | License Renewal |
| OC-403 (10/19) | Application for License to Appear on Behalf of, or Represent, Insurers and/or Self-Insurers | This form is to be completed by the qualifying officer of the Third-Party Administrator. | Workers’ Compensation Board, Licensing Bureau | New Application, Renewal Application, or New Qualifying Officer |
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OC-406 (1/18)
The Board will only accept the current version of this form. |
Notice of Retainer and Appearance on Behalf of Employer | Attorney representing employer before the Board in a no insurance, discrimination or double indemnity case. | Workers' Compensation Board | Immediately upon being retained. |
| 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 |
| OC-408 (10/16) | Licensed Representative’s Full Disclosure of Conflict of Interest to Client | Licensed Representatives of claimants, employers and insurers | Workers' Compensation Board and the client(s) of the licensed representative. | Whenever the licensed representative has an adverse interest or relationship with any of the parties to a proceeding. |
| OC-409 (2/12) | Initial Application to take License Representative Exam | This form is to be completed by individual taking exam. | Workers' Compensation Board, Licensing Bureau | Must be postmarked no later than three weeks prior to examination. |
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OT/PT-4 (7/20) Paper Version OT/PT-4 Online Submission] As of 7/1/22, CMS-1500 should be used. Information on the CMS-1500 Initiative |
Occupational/ Physical Therapist's Report | Occupational/ Physical Therapist | Workers' Compensation Board, insurer, referring doctor, injured employee or employee's representative |
48 hour initial report, within 48 hours of first treatment.
15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
| PFL-820.1 (3/18) | Supplement to Certificate of Insurance | Carriers insuring employers for disability and paid family leave benefits through Plan Coverage, Enriched Coverage, or Class Coverage | File with Form DB-820/829. | Attach to and make part of Form DB-820/829. |
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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 (C-7) cases. |
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PS-4 (10/15)
As of 7/1/22, CMS-1500 should be used. Information on the CMS-1500 Initiative |
Psychologist's Report | Psychologist | Workers' Compensation Board, insurer, injured employee or employee's representative |
48 hour initial report, within 48 hours of first treatment.
15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
| R (8/05) | Carrier's Report on Rehabilitation | Insurance Carrier/Board-approved self-insurer | Workers' Compensation Board, copy to claimant and claimant's 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. |
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RFA-1LC (5/22) Paper Version
The Board will only accept the current version of this form. [RFA-1LC Online Submission] 04/29/2022 - RFA Process Updates |
Request for Further Action by Legal Counsel | Claimant's Representative | Workers' Compensation Board, with copy to employer's insurance carrier or directly to employer or third-party administrator if employer is a Board-approved self-insurer. | 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. Note: When filing required documents (e.g., medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name, and date of injury. |
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RFA-1W (5/22) Paper Version
[RFA-1W Online Submission] |
Request for Assistance by Injured Worker | Claimant | Workers' Compensation Board | The form may be filed at any time after the Board assigns a WCB case number, or any time after the Board has indicated that no further action (NFA) will be taken. Note: When filing required documents (e.g., medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. |
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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 claimant's 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. Note: When filing required documents (e.g., medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name, and date of injury. |
| SI-1 (08/23) | Application for Self-Insurance | Employers | Filed by an applicant for self-insurance under the WCL | When appropriate |
| SI-12 (7/23) | Certificate of NYS Workers' Compensation Self-Insurance Coverage | 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. | Upon obtaining a permit, license, or contract from a government agency. Board-approved self-insured employers must obtain this form from the Board's Self-Insurance Office by emailing selfinsurance@wcb.ny.gov |
| SI-26 (11/16) | Notice of Election by a Political Subdivision, Ambulance or Fire District (for Self-Insurance) | Political subdivision, ambulance or fire district | Notice to the Chair that a political subdivision, ambulance or fire district has elected to secure compensation as a self-insurer | When appropriate |
| SI-105.2P (2/13) | Certificate of Participation in Workers' Compensation County Self-Insurance Plan | Employers participating in county self-insurance plans for workers' compensation | Filed with the government agency issuing a permit, license or contract. The SI-105.2P must be completed by the county self-insurance administrator. | Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their county self-insurance administrator. For further information contact the Board's Self-Insurance Office at (518) 402-0247 |
| SIG-105.2 (1/12) | 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 SIG-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. |
| SP-Affirmation (12/19) | Supervising Physician Affirmation | Physician Assistant | Workers' Compensation Board | Attached to Initial Request for Authorization and whenever a new supervising physician is reported to the Board. |
| 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. |
| VAW-1 (8/97) | Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death | Volunteer Ambulance Worker | Send to political subdivision liable for benefits. [This is not a claim for benefits. See VAW-3] | Within 90 days after date of injury or death (unless claim form VAW-3 or VAW-62 is filed within that period). |
| VAW-3 (6/22) | Volunteer Ambulance Worker's Claim for Benefits | Volunteer Ambulance Worker | Workers' Compensation Board, and political subdivision liable for benefits. [If filed within 90 days of injury, it is not necessary to file VAW-1.] | Within 2 years after injury is incurred. |
| VAW-62 (1/11) | Claim for Volunteer Ambulance Workers' Benefits in a Death Case | Claimant | Workers' Compensation Board and designated officer (see detailed instructions on form) | Within two years after death (but see also Form VAW-1) |
| VAW-105 (9/16) | Notice of Compliance - Volunteer Ambulance Workers' Law | Political Subdivision or Unaffiliated Volunteer Ambulance Service insured for Volunteer Ambulance Workers' Benefits 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 political subdivision or unaffiliated ambulance service with identifying insurance information and then displayed in the ambulance company headquarters. |
Upon securing of volunteer ambulance workers' insurance or self-insurance. Political subdivisions or unaffiliated ambulance services must obtain this form from their insurance carrier or group self-insurance administrator.
Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
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VDF-1 (1/12)
[VDF-1 Online Submission] |
Loss of Wage Earning Capacity Vocational Data Form | Claimant | Workers' Compensation Board, copy to insurer | Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim. |
| VF-1 (8/97) | Notice to Political Subdivision of Volunteer Firefighter's Injury or Death | Volunteer Firefighter | Send to political subdivision liable for benefits. [This is not a claim for benefits. See VF-3] | Within 90 days after date of injury or death (unless claim form VF-3 or VF-62 is filed within that period) |
| VF-3 (6/22) | Volunteer Firefighter's Claim for Benefits | Volunteer Firefighter | Workers' Compensation Board, and political subdivision liable for benefits. [If filed within 90 days of injury, it is not necessary to file VF-1.] | Within 2 years after injury is incurred. |
| VF-62 (1/11) | Claim for Volunteer Firefighter Benefits in a Death Case | Claimant | Workers' Compensation Board and designated officer (see detailed instructions on form) | Within two years after death (but see also Form VF-1) |
| VF-105 (9/16) | Notice of Compliance - Volunteer Firefighters Benefit Law | Political Subdivision insured for Volunteer Firefighters' Benefits 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 political subdivision with identifying insurance information and then displayed in the firehouse and fire company headquarters. |
Upon securing of volunteer firefighters' insurance or self-insurance. Political subdivisions must obtain this form from their insurance carrier or group self-insurance administrator.
Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website. |
| VF/VAW-10 (12/21) | Insurer's Request for Benefit Increase Reimbursement Under Sec. 51 VFBL/VAWBL | Insurance Carrier/Self-Insurer | Send your request along with any required documentation to: SpecialFunds@wcb.ny.gov | Claims for reimbursement should be submitted for 52 week periods, beginning one year from the date of the first payment, and annually thereafter while payments continue. |
| VF/VAW-11C (6/22) | Volunteer's Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV Per VFBL/VAWBL Section 11-c(1) | Volunteer Firefighter or Volunteer Ambulance Worker | Executive Officer of Fire Company or Ambulance Company, copy to the Workers' Compensation Board |
Following significant risk of transmission of HIV incurred in the line of duty as a volunteer firefighter or ambulance worker.
Executive Officer must authorize appropriate medical examination within 8 hours of receipt of Form VF/VAW-11C. Contact the nearest office of the Workers' Compensation Board if authorization is not granted within that time. THIS FORM IS NOT A NOTICE OF INJURY/OCCUPATIONAL DISEASE OR A CLAIM FOR BENEFITS UNDER THE VFBL OR VAWBL. (See Forms VF-1, VAW-1, VF-3 and VAW-3) |
| WTC-12 (1/24) | Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL §162 | Employees or volunteers who participated in World Trade Center rescue, recovery and clean-up operations between 9-11-01 and 9-12-02. | Workers' Compensation Board | Not later than September 11, 2026 |
| 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 |
| WTC-HIPAA (4/17) | World Trade Center Volunteer Health Insurance Portability and Accountability Act Authorization | Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. | Workers' Compensation Board | File with Form WTCVol-3. See form for complete instructions. |
| WTC-VCF-AUTH (12/21) | World Trade Center September 11th Victim Compensation Fund (VCF) Authorization | Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. | Workers' Compensation Board | File with Form WTCVol-3. See form for complete instructions. |
| WTCVol-3 (6/22) | World Trade Center Volunteer's Claim for Compensation | Volunteer worker who suffered injury/illness at or near the World Trade Center (Ground Zero) or the Fresh Kills Landfill on or after 9-11-01. | Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 | After filing a timely WTC-12, file a claim. See form for complete instructions. |
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.
View a list of all prescribed Workers' Compensation Board forms