Workers’ Compensation Underwriting Forms |
| Form Number | Form Name | Purpose |
|---|
| 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 Number | Form Name | Purpose |
|---|
| 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 ten 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 version) |
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). |
| 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 |
As per reform legislation signed into law on March 13, 2007: - Distribute to all of your employees, either by hand or electronically, and
- Post in a prominent, well-lighted location frequented by employees.
|
| PBM Post-SP |
Aviso Importante Referente A Beneficios de Farmacias Para Compensación Obrera |
Por la legislación de la reforma con fecha del 13 de marzo de 2007: - Distribuya a todos sus empleados en el Estado de Nuevo York, a mano o electrónicamente;
- Poste en una localización prominente frecuentada por los empleados.
|
Workers’ Compensation Claim Forms – Injured Worker |
| Form Number | Form Name | Purpose |
|---|
| 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-3.1
C-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-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. |
Workers’ Compensation Claim Forms – Medical Provider |
| Form Number | Form Name | Purpose |
|---|
| 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 Number | Form Name | Purpose |
|---|
| DB-120 |
Notice of Compliance – Disability Benefits Law
Contact 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 Number | Form Name | Purpose |
|---|
| 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. |
Volunteer Firefighters Claim Forms |
| Form Number | Form Name | Purpose |
|---|
| 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 Number | Form Name | Purpose |
|---|
| 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. |