Essential Forms

Forms C-240, C-11 and C-107 are essential to avoid delays in claims payments, reimbursements and penalties. A C-105 Notice of Compliance is required by law to be posted in all business locations.

C-240: Employer's Statement of Wage Earnings Preceding Date of Accident

Promptly report accurate wage and attendance information about the injured worker to NYSIF by submitting Form C-240 to establish the validity of a claim and the compensation rate, if awarded.

C-11: Employer's Report of Injured Employee's Change in Status

Report any change in a claimant’s work status as soon as it occurs to NYSIF by submitting Form C-11, including return to work, discontinuance of work, decrease in regular working hours or reduction of wages.

C-107: Employer's Request for Reimbursement

Promptly report advance payments of compensation to the injured worker on Form C-107 to be reimbursed before the Workers’ Compensation Board makes a compensation award.

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