Print Forms Download frequently-used forms, including available multilingual forms, arranged by category below. (For more forms go to Workers' Compensation Board Common Forms.) Employers can refer to NYSIF's Policyholder pages for more information on when to file certain forms listed here. Workers' Compensation Underwriting Forms Workers' Compensation Claim Forms - Employer Workers' Compensation Claim Forms - Injured Worker Workers' Compensation Claim Forms - Medical Provider Disability Benefits Underwriting Forms Disability Benefits Claim Forms (non-job related injury or illness) Volunteer Firefighters Claim Forms Volunteer Ambulance Workers Claim Forms Adobe Acrobat Reader is required to view forms. You may download Download Adobe Reader. Workers’ Compensation Underwriting Forms Form NumberForm NamePurpose UE-4 Electronic eQuote System and Online Application (online reporting)Workers' Compensation Application (paper form) Informational questionnaire to determine eligibility for workers' compensation coverage and provides information needed to properly underwrite the risk. Fill out this questionnaire online using eQuote. C-105 Notice of Compliance Workers' Compensation Law requires that you post a Notice of Compliance, C-105, in all business locations. A C-105 was provided to you in your policy and renewal information packages. U-3, U-3a Assignment of Interest Agreement Transfer of Policy Interest U-111, U-111a Request for Inclusion of Additional Interest This form must be completed for each entity, including the FEINs, signed, and returned to NYSIF. Please have the form signed by a principal or an executive officer of the company you wish to add. No coverage will be issued if there is no combinability* between the entities. *Combinability – The same person, group of persons or corporation owns more than 50% of each entity. U-218 Executive Officer Information Sheet Form U-218 must be completed and returned to NYSIF in every case where there is a change of officers of a corporation presently insured by us or where a request is made to transfer the policy to a corporation. U-431 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 This form applies only to the Executive officers certified within and should be sent at once to NYSIF. A new form must be filed whenever new or additional executive officers are included. U-435 Notice of Election of a Municipal Corporation or Other Political Subdivision of the State to Bring Executive Officers Under the Coverage of the New York Workers’ Compensation Law This form applies only to the Executive officers certified within and should be sent at once to NYSIF. A new form must be filed whenever officers not described on this form are to be included. U-445 Experience Rating Plan – Request for Information Complete fully, in duplicate. The information requested is necessary for the completion of the Compensation Insurance Rating Board’s experience records. U-617, U-619 Notice to Corporations with One or Two Executive Officers who own all of the Corporation’s stock. Sole/Dual Executive Officer exclusion from workers' compensation coverage. U-626, U-627 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. If you are self-employed (sole proprietor) or a partner as defined in Section 10 of the Partnership Law or a member of an LLC, you can elect to be covered under your policy by completing and signing the letter, U-626, and the notice of election form, U-627 and returning both to NYSIF. U-629 Notice of election of a Not-for-Profit Corporation or a Not-for-Profit Unincorporated Association to exclude an unsalaried executive officer from coverage pursuant to Section 54, subdivision 6 of the Workers’ Compensation Law. A Not-for-Profit Corporation or a Not-for-Profit Unincorporated Association may exclude an unsalaried executive officer from coverage. U-21.1 Volunteer Firefighters Application Informational questionnaire to determine eligibility for Volunteer Firefighters' coverage and provides information needed to properly underwrite the risk. U-718 Volunteer Ambulance Workers Application Informational questionnaire to determine eligibility for Volunteer Ambulance Workers' coverage and provides information needed to properly underwrite the risk. U-765 Roofing Contractors Supplemental Questionnaires This form is required for businesses engaged in the installation or repair of residential or commercial building roofs. Attach form to workers' compensation application for insurance (UE-4). U-766 Building Demolition Supplemental Questionnaires Questionnaire that is required to obtain a demolition certificate of insurance. Workers’ Compensation Claim Forms - Employer Form NumberForm NamePurpose C-2 Electronic Employer's Report of Work-Related Injury/Illness (online reporting)Employer's Report of Work-Related Injury/Illness (paper form) To be filed by the employer within 10 days after of the employer’s knowledge of a work-related injury, provided the injury has caused or will cause the injured employee’s loss of time from regular duties of one day beyond the workday or shift during which the accident occurred; or has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid. Claimant Information Packet Claimant Information Packet This information must be provided by the employer to the injured employee before filing the Employer's Report of Work-Related Injury/Illness (C-2). Compendio Información Reclamante (Claimant Information Packet, Spanish) Compendio Información Reclamante El patrón debe proveerle esta información al empleado lesionado antes de rendir el formulario C-2 Employer’s Report of Work Related Injury/Illness (Aviso del Empresario sobre Lesión o Enfermedad Relacionada al Trabajo). 索赔人信息包 员工索赔 Claimant Information Packet (Chinese) Aplikasyon enfòmasyon Paquet Demann Anplwaye Claimant Information Packet (Haitian-Creole) Pacchetto di informazioni richiedente Richiesta di indennizzo da parte del dipendente Claimant Information Packet (Italian) 청구 정보 패킷 직원 청구서 Claimant Information Packet (Korean) Wnioskodawca pakiet informacji Wniosek pracownika Claimant Information Packet (Polish) Пачка Информации Претендента Заявление работника Claimant Information Packet (Russian) C-11 Employer's Report of Injured Employee's Change in Employment Status Resulting from Injury Employer's Report of Injured Employee's Change in Status or Return to Work. File this form as soon as employment status of injured employee changes. Change in employment status includes return to work, discontinuance from work, an increase or decrease of regular hours of work. C-107 Employer's Request for Reimbursement This form is used for policyholders to request reimbursement for wages paid to an injured employee. C-240 Employer's Statement of Wage Earnings Preceding Date of Accident To be filed within 10 days of request by the WCB, failure to do so results in penalties. PBM Post Important Notification Concerning Workers’ Compensation Pharmacy Benefits Post on employee accessible intranet or Internet website, or Post in the same location where the Notice of Workers' Compensation Coverage is posted, or Distribute a paper or electronic copy of the PBM Notice to all of your employees in New York State. PBM Post-SP Aviso Importante Referente A Beneficios de Farmacias Para Compensación Obrera Publicar en la intranet accesible para el empleado o en el sitio web en Internet, Publicar en el mismo lugar donde se coloca el Aviso de cobertura de compensación de trabajadores, o Distribuir una copa electrónica o impresa del Aviso del PBM a todos sus empleados en el Estado de Nueva York. PBM Post-Chinese 工伤赔偿药房福利公告 开机自检时,在员工访问内部网或互联网网站,或在开机自检的同一 位置,通知工人的补偿范围,或分发一 个纸张或电子副本的PBM的通知您所有的员工在纽约州. PBM Post-Haitian-Creole AVI KONSÈNAN AVANTAJ FAMASI POU KONPANSASYON TRAVAYÈ Post sou entranèt anplwaye ki aksesib oswa sou sit wèb entènèt, oswa Post nan kote a menm ki kote Avi sou konvèti asirans konpansasyon travayè ki afiche, oswa Distribye yon papye oswa elektwonik kopi Avi PBM nan tout anplwaye ou yo nan Eta New York. PBM Post-Italian COMUNICAZIONE SU PRESTAZIONI FORNITE DA FARMACIE IN CASO DI INDENNITÀ PER INFORTUNI SUL LAVORO Posta sul dipendente intranet accessibile o sito Internet, o Posta nella stessa posizione in cui è pubblicato l'avviso di compensazione copertura dei lavoratori, o Distribuire una carta o copia elettronica della PBM Avviso per tutti i dipendenti nello Stato di New York. PBM Post-Korean 근로자의 보상 의약품 혜택 관련 안내문 액세스할 수 POST 직원 인트라넷 또는 인터넷 홈페이지에, 또는 직원들의 보상 범위의 주의사항 게시, 또는 PBM 통보 종이 또는 전자 사본 모든 직원에게 뉴욕 주에서 배포할 수 있는 동일한 위치에 포스트. PBM Post-Polish POWIADOMIENIE DOTYCZĄCE ŚWIADCZEŃ FARMACEUTYCZNYCH W RAMACH ODSZKODOWANIA PRACOWNICZEGO Opublikuj na pracowników dostępnym intranecie lub stronie internetowej, lub Zamieść w tym samym miejscu, w którym zawiadomienie o pokryciu pracowników odszkodowania jest delegowany, lub Rozpowszechnianie papieru lub elektroniczną kopię PBM Informacja dla wszystkich pracowników w stanie Nowy Jork. PBM Post-Russian УВЕДОМЛЕНИЕ ОТНОСИТЕЛЬНО ФАРМАЦЕВТИЧЕСКИХ ЛЬГОТ ПРИ ПРОИЗВОДСТВЕННЫХ ТРАВМАХ Сообщение на сотрудника доступным интрасети или в Интернете веб-сайт, или Сообщение в том же месте, где покрытие Уведомление о компенсации работникам зарегистрирована, Распределить бумажных или электронных копий PBM уведомлением всех ваших сотрудников в штате Нью-Йорк. Workers’ Compensation Claim Forms – Injured Worker Form NumberForm NamePurpose C-3 Employee's Claim for Compensation To be filed by the claimant when making a claim within two years of accident, or within two years after employee knew or should have known that injury or illness was related to employment. C-3S Forma C-3S, Reclamación de Compensación Para Empleados El proposito de esta guîá es ayudar a personas cuya lengua primaria es el español a llenar la Forma C-3, que se utiliza para radicar una reclamación de compensación. Contiene una traducción y explicación a cada pregunta . Si es posible llene la forma en inglés, para que su reclamación pueda ser procesada por personal que no entienda español. El reverso de la Forma C-3 contiene información en español sobre que hacer en caso de que sufra una lesión en su trabajo, los derechos por ley y donde radicar su reclamación. C-3.1C-3.1S Spanish version on reverse Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider Completed by injured employee when employer 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. C-3.1CChinese 关于选择劳工赔偿局授权医疗服务提供者的权利的通知 Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider (Chinese) C-3.1HHaitian-Creole Avi pou Dwa pou Chwazi yon Founisè Swen Sante ki Gen Otorizasyon Komisyon Konpansasyon Travayè Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider (Haitian-Creole) C-3.1IItalian Informativa sul diritto di scelta di un professionista/struttura sanitaria autorizzato dalla Workers' Compensation Board Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider (Italian) C-3.1KKorean 근로자재해보상위원회가 승인한 의료 제공자를 선택할 권리에 관한통지서 Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider (Korean) C-3.1PPolish Informacja o prawie do wyboru dostawcy usług medycznych zatwierdzonego przez Komisję ds. Odszkodowań Pracowniczych Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider (Polish) C-3.1RRussian Извещение о праве выбора поставщика медицинских услуг, уполномоченного Управлением по компенсациям работникам Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider (Russian) C-3.3SLimited Release of Health Information (HIPAA)Spanish Divulgación limitada de información sobre la salud Limited Release of Health Information - HIPPA (Spanish) C-3.3CChinese 健康信息的有限披露 Limited Release of Health Information - HIPPA (Chinese) C-3.3HHatian-Creole Divilgasyon Limite Enfòmasyon sou Sante Limited Release of Health Information - HIPPA (Hatian-Creole) C-3.3IItalian Richiesta di divulgazione parziale delle informazioni sanitarie Limited Release of Health Information - HIPPA (Italian) C-3.3KKorean 건강 정보의 제한적 공개 Limited Release of Health Information - HIPPA (Korean) C-3.3PPolish Ograniczony zakres ujawniania informacji o stanie zdrowia Limited Release of Health Information - HIPPA (Polish) C-3.3RRussian Ограниченное разрешение на предоставление информации о состоянии здоровья (Закон о преемственности страхования Limited Release of Health Information - HIPPA (Russian) C-257 Claimant’s Record of Medical and Travel Expenses To be used by claimant to keep a record of reimbursable expenses in connection with a workers' compensation case. Bring completed form, with receipts, to hearings and present to Workers' Compensation Law Judge. OC-110A Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) Claimant’s authorization must be submitted with original signature in order to allow release of his/her records to parties not otherwise authorized to receive them. OC-110ASSpanish AUTORIZACIÓN DE RECLAMANTE PARA PERMITIR ACCESO A EXPEDIENTES ANTE LA JUNTA Claimant's Authorization to Disclose Workers' Compensation Records (Spanish) OC-110ACChinese 劳工赔偿局索赔人对劳工赔偿记录之披露授权 Claimant's Authorization to Disclose Workers' Compensation Records (Chinese) OC-110AHHaitian-Creole OTORIZASYON MOUN KI MANDE KONPANSASYON POU DIVILGE DOSYE KONPANSASYON TRAVAYÈ Claimant's Authorization to Disclose Workers' Compensation Records (Haitian-Creole) OC-110AIItalian AUTORIZZAZIONE DEL RICHIEDENTE ALLA DIVULGAZIONE DEGLI ATTI DELL'INDENNIZZO PER INFORTUNIO SUL LAVORO Claimant's Authorization to Disclose Workers' Compensation Records (Italian) OC-110AKKorean 뉴욕주 직원상해보험위원회 직원 상해보험 기록 공개에 대한 청구인의 승인 Claimant's Authorization to Disclose Workers' Compensation Records (Korean) OC-110APPolish UPOWAŻNIENIE DO UJAWNIENIA AKT SPRAWY O ODSZKODOWANIE PRACOWNICZE Claimant's Authorization to Disclose Workers' Compensation Records (Polish) OC-110ARRussian РАЗРЕШЕНИЕ ЗАЯВИТЕЛЯ НА РАСКРЫТИЕ СВОЕГО ДОСЬЕ ПО КОМПЕНСАЦИИ Claimant's Authorization to Disclose Workers' Compensation Records (Russian) Workers’ Compensation Claim Forms – Medical Provider Form NumberForm NamePurpose C-4 Attending Doctor’s Report To be filed as a 48 hour initial report, within 48 hours of first treatment; 15 day report, within 17 days of first treatment; 45 day progress report, at 45 day intervals while continuing treatment: always with detailed information of your findings. C-4.1 Continuation to Carrier/Employer Billing Section C-4, C-5, PS-4 or OT/PT-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-5, PS-4 and OT/PT-4) C-5 Attending Ophthalmologist's Report To be filed as a 48 hour initial report, within 48 hours of first treatment; 15 day report, within 17 days of first treatment; 45 day progress report, at 45 day intervals while continuing treatment: always with detailed information of your findings. C-64 Proof of Death by Physician Last in Attendance on Deceased To be filed upon death of claimant, or when requested by WCB. C-72.1 Record of Percentage Hearing Loss To be filed upon completion of audiometric test battery. FCE-4 Practitioner’s Report of Functional Capacity Evaluation The Functional Capacity Evaluation (FCE) is used to determine the level of safe maximal function at the time of maximum medical improvement; to determine whether additional treatment or referral to a work hardening program is indicated. Page 2 of the FCE-4 provides greater detail. OT/PT-4 OT/PT–4 “Occupational Therapist’s or Physical Therapist’s Report To be filed as a 48 hour initial report, within 48 hours of first treatment; 15 day report, within 17 days of first treatment; 45 day progress report, at 45 day intervals while continuing treatment: always with detailed information of your findings. Disability Benefits Underwriting Forms Form NumberForm NamePurpose DB-120 Notice of Compliance – Disability Benefits LawContact us if you did not receive in your DB policy or renewal package. To be posted in all business locations to show proof of disability benefits insurance. A DB-120 is provided in both the DB policy and renewal information packages. DB-135 Employer’s Application for Voluntary Coverage (No Employee Contribution) To voluntarily cover employees for whom DB is not required under the Law with no employee contributions to the cost of the coverage. This form is filed by the employer to the WCB, DB Bureau, Albany. DB-136 Employer’s Application for Voluntary Coverage (Employee Contribution) To voluntarily cover employees for whom DB is not required under the Law with employee contributions to the cost of the coverage. This form is filed by the employer to the WCB, DB Bureau, Albany. DB-212.3 Notice of Election of a Corporation Which is Required to Have Disability Benefits Coverage for its Employees to Exclude the Sole Shareholder Officer or One of the Two or Both Shareholder Officers of the Corporation from Such Coverage Officers are deemed included in insurance contract until election to exclude is filed. File with insurance carrier. Board approved self-insured employers file with WCB Self-Insurance Office. DB-212.5 Notice of Election to Voluntarily Exclude Spouse from Coverage To voluntarily exclude spouse from DB coverage. Form is filed with carrier or, if Board approved self-insurer (or no carrier and spouse is only employee), with the WCB. UDB-112 Request for Inclusion of Additional Interest To add an additional entity to a disability benefits policy. The form must be completed in full, signed by a principal or executive officer of both the existing and new company and returned to NYSIF. UDB-36 Application for Disability Benefits Insurance To apply for disability benefits insurance with NYSIF. Complete application and mail with deposit check to: NYSIF – Disability Benefits, 15 Computer Drive West, Albany, NY 12205. UDB-36A Application for Disability Benefits Insurance Directions Directions on how to apply for disability benefits insurance with NYSIF. Complete application and mail with deposit check to: NYSIF – Disability Benefits, 15 Computer Drive West, Albany, NY 12205. UDB-SOC Selection of Disability Benefits Insurance Coverage Change Form Selection of Disability Benefits Insurance coverage change form is used by Policyholders that already have coverage and want to change their selection.. UDB-37 Assignment of Interest Agreement To transfer or assign the interest in a policy to another legal entity. Disability Benefits Claim Forms (non-job related injury or illness) Form NumberForm NamePurpose DB-300 Notice and Proof of Claim for Disability Benefits by Unemployed Claimant To be filed with WCB, Disability Benefits Bureau, Albany, if sick or disabled after 4 weeks of unemployment. File no later than 30 days after becoming sick or disabled. DB-450 Notice and Proof of Claim for Disability Benefits Please note: Part C (employer’s statement) must be completed by employer to ensure timely handling of claim. – please be sure to provide your NYSIF DB policy number. To be filed with employer’s insurance company if an employee becomes disabled while employed or within four weeks after termination. File no later than 30 days after becoming sick or disabled. DB-450Spanish Information Sheet for Form DB-450 GUÍA PARA LLENAR EL FORMULARIO DB-450, NOTIFICACIÓN Y CONSTANCIA DE LA SOLICITUD DE LOS BENEFICIOS POR INCAPACIDAD Esta guía pretende ayudarles a las personas que hablan español como primer idioma a llenar el Formulario DB-450, que se usa con mayor frecuencia para solicitar los beneficios por incapacidad del Estado de Nueva York (por lesiones o enfermedades sufridas fuera del trabajo). Contiene una traducción de las instrucciones y preguntas que deberá responder en el formulario. Si puede, llene la Parte A del Formulario DB-450 en inglés y siga las instrucciones que se brindan a continuación para presentar la solicitud. El proveedor de servicios de salud que le brinde asistencia médica deberá llenar la Parte B ubicada al dorso del formulario antes de que usted lo presente. No presente esta guía junto con la solicitud. Volunteer Firefighters Claim Forms Form NumberForm NamePurpose VF-2 Political Subdivision's Report of Injury to Volunteer Firefighter Political Subdivision (Company) is to submit within 10 days after injury is incurred. VF-3 Volunteer Firefighter's Claim for Benefits Claimant files claim for benefit. VF-62 Claim for Volunteer Firefighter Benefits in a Death Case Claimant files claim for benefit on a death case. Volunteer Ambulance Workers Claim Forms Form NumberForm NamePurpose VAW-2 Political Subdivision's Report of Injury to Volunteer Ambulance Worker Political Subdivision (Company) is to submit within 10 days after injury is incurred. VAW-3 Volunteer Ambulance Worker's Claim for Benefits Claimant files claim for benefit. VAW-62 Claim for Volunteer Ambulance Workers' Benefits in a Death Case Claimant files claim for benefit on a death case.