Commonly Used Forms

If you are a prospective or current policyholder and received an eSignature form request from NYSIF, please note it will appear in your inbox as "Electronic Form via DocuSign," with the name of the form as the subject line.

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Access frequently-used workers' compensation and disability benefits forms below. Many of the forms link directly to the Workers' Compensation Board website.

Form Name/Description
eQuote/eApplication Electronic Quote System and Online Application - application for workers' compensation insurance.
UE-4 Application for Workers' Compensation Insurance (paper form)
UE-4Dm Application for Workers' Compensation Insurance for Domestic Household Workers (paper form)
C-105 Workers’ Compensation Law requires you to post your C-105 Notice of Compliance in all business locations.
U-3, U-3a Assignment (Transfer) of Policy Interest Agreement
U-111, U-111a Request for Inclusion of Additional Interest must be completed for each entity, signed by a principal or executive officer of the entity you wish to add, and returned to NYSIF. Coverage is not issued unless the same person, group or corporation owns more than 50% of each entity.
U-218 Executive Officer Information Sheet - submit to NYSIF for all cases in which there is a change of officers of a corporation insured by us, or 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 NY Workers’ Compensation Law - submit to NYSIF whenever a certified new or additional executive officer is included for coverage.
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 NY Workers’ Compensation Law - submit to NYSIF whenever a certified new or additional executive officer is included for coverage.
U-445 Experience Rating Plan Request for Information - submit to NYSIF in duplicate, necessary for completion of NY Compensation Insurance Rating Board experience records.
U-617, U-619 Notice to Corporations with One or Two Executive Officers Who Own All of the Corporation’s Stock - submit to NYSIF for 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 Coverage of the NY Workers’ Compensation Law - submit to NYSIF when electing to cover any referenced party.
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 NY Workers’ Compensation Law - submit to NYSIF when electing to cover any referenced party.
U-21.1 Volunteer Firefighters' Application for workers’ compensation insurance coverage.
U-718 Volunteer Ambulance Workers’ Application for workers’ compensation insurance coverage.
U-765 Roofing Contractors Supplemental Questionnaire (attach to Form UE-4, Application for Workers’ Compensation Insurance) - required for businesses engaged in the installation or repair of residential or commercial building roofs.
U-766 Building Demolition Supplemental Questionnaire - required to obtain a demolition certificate of insurance.
U-89A Standard request for workers' compensation policy cancellation (See: About Your Policy: Cancellations)
Form Name/Description
FROI-00

C-2F (paper form for reference purposes)
Electronic First Report of Work-Related Injury/Illness - filed by the employer within 10 days of knowledge of a work-related injury/illness that:
  • has caused or will cause the injured employee’s loss of time from regular duties of one day beyond the workday or shift in 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 Info Packet Must be provided by the employer to the injured employee before filing First Report of Injury (FROI-00).
কর্মচারীর দাবি Claimant Information Packet (Bengali) 
Compendio Información Reclamante Claimant Information Packet (Spanish)
索赔人信息包 Claimant Information Packet (Traditional Chinese)
Aplikasyon enfòmasyon Paquet Claimant Information Packet (Haitian-Creole)
Pacchetto di informazioni richiedente Claimant Information Packet (Italian)
청구 정보 패킷 Claimant Information Packet (Korean)
Wnioskodawca pakiet informacji Claimant Information Packet (Polish)
Пачка Информации Претендента Claimant Information Packet (Russian)
C-11 Employer's Report of Injured Employee's Change in Employment Status Resulting From Injury - file to report an injured employee’s change in employment status including return to work, discontinuance, or increase or decrease of regular work hours.
C-107 Employer's Request for Reimbursement - file for reimbursement for wages paid to an injured employee.
C-240 Employer's Statement of Wage Earnings Preceding Date of Accident - failure to file within 10 days of request by the WCB may result in penalties.
C-256.2  New York State Agency's Request for Reimbursement - file for reimbursement for wages paid to an injured state employee. 
PBM Notice to Post
  • 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.
কর্মচারীদের ক্ষতিপুরনে ফার্মেসীর প্রদেয় সুমেগ সুবিধা সম্পর্কিত বিজ্ঞপ্তি PBM Notice to Post (Bengali)
বীমা গ্রাহকগন - দয়া করে স্পষ্টভাবে পোস্ট করুন
Aviso Importante Referente A Beneficios de Farmacias Para Compensación Obrera PBM Notice to Post (Spanish)
  • 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.
工伤赔偿药房福利公告 PBM Notice to Post (Chinese)
  • 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.
AVI KONSÈNAN AVANTAJ FAMASI POU KONPANSASYON TRAVAYÈ PBM Notice to Post (Haitian-Creole)
  • 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.
Comunicazione Su Prestazioni Fornite Da Farmacie In Caso Di Indennità Per Infortuni Sul Lavoro PBM Notice to Post (Italian)
  • 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.
근로자의 보상 의약품 혜택 관련 안내문 PBM Notice to Post (Korean)
  • 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.
Powiadomienie Dotyczące Świadczeń Farmaceutycznych W Ramach Odszkodowania Pracowniczego PBM Notice to Post (Polish)
  • 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.
УВЕДОМЛЕНИЕ ОТНОСИТЕЛЬНО ФАРМАЦЕВТИЧЕСКИХ ЛЬГОТ ПРИ ПРОИЗВОДСТВЕННЫХ ТРАВМАХ PBM Notice to Post (Russian)
  • 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.
Form/Language Name/Description
C-3 (English) Employee's Claim for Compensation - filed by the employee when making a claim within two years of injury/illness, or within two years after employee knew or should have known that injury or illness was related to employment.
C-3.1 (English) Notice of Right to Select a Workers' Compensation Board Authorized Health Care Provider - Completed by claimant, retained by employer, providing notice of the right to use any WCB authorized medical provider at any time for treatment (included with Claimant Information Packet). Do not submit to the WCB.
C-3.3 (English) Limited Release of Health Information HIPAA
C-257 (English) Claimant’s Record of Medical and Travel Expenses - Used by claimant to keep a record of reimbursable expenses in a workers' comp case. Present the form with receipts at hearings.
OC-110A (English) Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) - must be submitted with original signature.
বাঙালি আহত শ্রমিকের ফর্মগুলি (Bengali)
Kreyòl ayisyen Fòm Anplwaye ki Domaje yo (Haitian-Creole)
Italiano Moduli lavoratore feriti (Italian)
한국어 부상당한 근로자 양식 (Korean)
Język polski Formularze poszkodowanego pracownika (Polish)
Русский Пострадавший рабочий формирует (Russian)
Español Formularios de Trabajador lesionado (Spanish)
繁體字 受伤的工人表格 (Traditional Chinese)
Form Name/Description
C-4 Attending Doctor’s Report - physician files as follows:
  • 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 include detailed information of your findings.
C-4.1 Continuation to Carrier/Employer Billing Section C-4, C-5, PS-4 or OT/PT-4 - Used for more than six dates of service.
C-5 Attending Ophthalmologist's Report - ophthalmologist files as follows:
  • 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 include detailed information of your findings.
C-64 Proof of Death by Physician Last in Attendance on Deceased - filed upon death of a claimant, or when requested by WCB.
C-72.1 Record of Percentage Hearing Loss - filed upon completion of an audiometric test battery.
FCE-4 Practitioner’s Report of Functional Capacity Evaluation - determines the level of safe maximal function at the time of maximum medical improvement.
OT/PT-4 Occupational/Physical Therapist Report - therapist files as follows:
  • 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 include detailed information of your findings.
Form Name/Description
DB-120
PFL-120
Disability Benefits Law & Paid Family Leave Law Notices of Compliance - must be posted in all business locations to show proof of disability benefits and paid family leave insurance. Contact us if you did not receive these with your policy.
UDB-36 Application for NYSIF Disability Benefits & Paid Family Leave Insurance - submit with deposit to NYSIF to apply for disability benefits/PFL insurance.
UDB-37 Assignment of Interest Agreement - transfers or assigns the interest in a DB policy to another legal entity.
UDB-89  Request for voluntary cancellation of disability benefits policy (See: Amending a Policy)
UDB-112 Request for Inclusion of Additional Interest - submit to NYSIF, signed by a principal or executive officer of both the existing and new company, to add an entity to a DB policy.
DB-135 Employer’s Application for Voluntary Coverage (No Employee Contribution) - submit to WCB DB Bureau, Schenectady, NY, to provide coverage at no cost to employees for whom DB is not required.
PFL-135 Employer’s Application for Voluntary Coverage (No Employee Contribution) - submit to WCB DB Bureau, Schenectady, NY, to provide coverage at no cost to employees for whom PFL is not required.
DB-136 Employer’s Application for Voluntary Coverage (Employee Contribution) - submit to WCB DB Bureau, Schenectady, NY, to provide coverage to employees for whom DB is not required, but for which they agree to contribute.
PFL-136 Employer’s Application for Voluntary Coverage (Employee Contribution) - submit to WCB DB Bureau, Schenectady, NY, to provide coverage to employees for whom PFL is not required, but for which they agree to contribute.
DB-212.3 Notice of Election of a Corporation Which is Required to Have Disability and Paid Family Leave 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 - submit to NYSIF to exclude officers from DB & PFL coverage, or to WCB DB Bureau, Schenectady, NY, if you are an approved self-insured employer.
DB-212.5 Notice of Election to Voluntarily Exclude Spouse from Coverage - submit to WCB DB Bureau, Schenectady, NY, to voluntarily exclude spouse from DB & PFL coverage.
UDB-SOC Selection of Disability Benefits Insurance Coverage Change Form - submit to NYSIF to change coverage for DB policyholders.
Form Name/Description
PFL Employer Checklist NYSIF PFL Checklist for Employers - to assist NYSIF DB/PFL policyholders in complying with PFL requirements
PFL-271S - 2019 Statement of Rights for Paid Family Leave - Employers must provide the Employee Statement of Rights to employees when they take Paid Family Leave or take time off from work for a Paid Family Leave qualifying event, but have not requested PFL. (This link provides this form in other languages.)
PFL-Waiver Employee Paid Family Leave Opt-Out & Waiver of Benefits - Provide to the employee if he/she does not expect to work long enough to qualify for Paid Family Leave (a seasonal worker, for example) to opt out of PFL.
PFL-DC-130 Employer's Response to Paid Family Leave Discrimination/Retaliation Complaint - Within 30 days of receiving a notice of Paid Family Leave Discrimination/Retaliation complaint (form PFL-DC-129) from the Board, employers must complete and submit this form to the Board or risk waiver of your defenses. Mail this form to Paid Family Leave, PO Box 9030, Endicott, NY 13761-9030.
Form Name/Description
NYSIF DB-450 Notice and Proof of Claim for Disability Benefits - Submit to NYSIF if you become disabled while employed or within four weeks after termination, and no later than 30 days after you become sick or disabled. Part C (employer’s statement) must be completed by the employer and include the employer's NYSIF DB policy number.
DB-450 Spanish Info Sheet 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).
NYSIF PFL BONDING Pre-file or file a Paid Family Leave claim to Bond with a Newborn, a Newly Adopted Child or Fostered Child (included: Claimant Checklist, NYSIF PFL-1 & NYSIF PFL-2)
PFL Bonding - Translations File a Paid Family Leave claim to Bond with a Newborn, a Newly Adopted Child or Fostered Child
NYSIF PFL CARE Pre-file or file a Paid Family Leave claim to Care for a Family Member with Serious Health Condition (included: Claimant Checklist, NYSIF PFL-1, NYSIF PFL-3, NYSIF PFL-4A & NYSIF PFL-4B)
PFL Care - Translations File a Paid Family Leave claim to Care for a Family Member with Serious Health Condition
NYSIF PFL MILITARY  Pre-file or file a Paid Family Leave claim to Assist with Matters Arising from a Family Member's Call to Active Duty or Deployment (included: Claimant Checklist, NYSIF PFL-1, NYSIF PFL-5 & NYSIF PFL-5T)
PFL Military - Translations File a Paid Family Leave claim to Assist with Matters Arising from a Family Member's Call to Active Duty or Deployment
PFL-DC-119 Employee Formal Request for Reinstatement Regarding Paid Family Leave - submit to formally request reinstatement to the same or comparable position from their employer.
PFL-DC-120 Employee Paid Family Leave Discrimination/Retaliation Complaint - submit a PFL-DC-120 when the employer has not replied within 30 days or they were not satisfied with the employer’s response to their Formal Request for Reinstatement Regarding Paid Family Leave (PFL-DC-119).
DD-APP-DBL English  NYSIF offers online direct deposit enrollment for disability benefits claimants.
DD-APP-DBL Spanish  NYSIF ofrece un depósito directo para que las personas que soliciten beneficios por discapacidad puedan recibirlos.
DD-APP-DBL Traditional Chinese  紐約州保險基金 (NYSIF) 提供直接付款方式,供殘障福利金申領人取得殘障福利金
DD-APP-DBL Haitian-Creole NYSIF ofri a moun k ap reklame avantaj pou andikap (disability benefits) pou yo resevwa avantaj pou andikap yo a nan depo dirèk.
DD-APP-DBL Italian  Il Fondo di garanzia dello Stato di New York (New York State Insurance Fund, NYSIF) offre ai richiedenti di sussidi di invalidità la possibilità di ricevere l’accredito diretto.
DD-APP-DBL Korean  NYSIF는 장애인 수당 청구인이 장애인 수당을 받을 수 있는 자동이체 서비스를 제공합니다.
DD-APP-DBL Polish  NYSIF oferuje opcję przelewu bankowego zasiłku z tytułu niezdolności do pracy dla osób ubiegających się o tego typu świadczenia.
DD-APP-DBL Russian  NYSIF предлагает получателям пособия по нетрудоспособности воспользоваться прямым переводом на счет выплат по этому пособию.
DD-APP-DBL-Bengali NYSIF নিউ ইয়র্ক স্টেট বীমা তহবিল অক্ষমতাহেতু ক্ষতিপুরন দাবীর প্রদেয় অর্থ সরাসরি জমাদানের সুযোগ দিচ্ছে।
Form Name/Description
VF-1 Notice to Liable Political Subdivision of Volunteer Firefighter’s Injury or Death - submitted by the injured party to fire company or political subdivision liable for benefits within 90 days after date of injury or death (unless form VF-3 or VF-62 is filed within that period).
VF-3 Volunteer Firefighter's Claim for Benefits - submit to the WCB to file a claim for benefits.
VF-62 Claim for Volunteer Firefighter Benefits in a Death Case - submit to WCB to file a claim for benefits in a death case.
Form Name/Description
VAW-1 Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death - submitted by the injured party to political subdivision liable for benefits within 90 days after date of injury or death (unless form VAW-3 or VAW-62 is filed within that period).
VAW-3 Volunteer Ambulance Worker's Claim for Benefits - submit to the WCB to file a claim for benefits.
VAW-62 Claim for Volunteer Ambulance Workers' Benefits in a Death Case - submit to WCB to file a claim for benefits in a death case.

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