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Forms

Frequently-used forms are available when you want them. They’re collected here, in one place, accessible from the top of every page, for you to view online, print and complete. In addition to business forms for both policyholders and brokers, we encourage you to use our safety checklists, tip sheets and other resource materials.

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

Workers’ Compensation Underwriting Forms

Form Number Form Name Purpose
UE-4 Workers' Compensation Application 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 Employer's Report of Work-Related Injury/Illness  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-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-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.


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