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. Instructions
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.
In addition to the above forms, NYSIF has made its 10 most commonly-used workers’ compensation forms available for electronic signature through DocuSign. This electronic process will expedite form submission.
If you are required to complete one of the following forms, your NYSIF underwriter may request your email address to initiate the electronic signature process in DocuSign. Quick and simple, you will receive an email notification that the online document is available to complete and sign electronically. Once executed, both NYSIF and the policyholder will receive email confirmation, along with a link to the final form.
When NYSIF transmits the form to you, it will appear in your inbox as "Electronic Form via DocuSign," with the name of the form as the subject line.
The following eSignature Forms are available:
- U-3 and U-3A Assignment of Interest
- U-111 and U-111A Request for Inclusion of Additional Interest (Entity)
- U-431 Notice of election coverage of NY workers' compensation
- U-445 Experience Ratings Plan Request for Additional Information
- U-619 Exclusion Form (with U-617 notification)
- U-626 and U-627 Election of Coverage for LLP, LLC, Sole Proprietors, etc.
- U-629 Notice of non-profit to exclude unsalaried executive officer
- U-765 Roofing Contractors Supplemental Questionnaire
- U-766 Building Demolition Supplemental Questionnaire