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.
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:
|
| 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 |
|
| 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)
|
| 工伤赔偿药房福利公告 |
PBM Notice to Post (Chinese)
|
| AVI KONSÈNAN AVANTAJ FAMASI POU KONPANSASYON TRAVAYÈ |
PBM Notice to Post (Haitian-Creole)
|
| Comunicazione Su Prestazioni Fornite Da Farmacie In Caso Di Indennità Per Infortuni Sul Lavoro |
PBM Notice to Post (Italian)
|
| 근로자의 보상 의약품 혜택 관련 안내문 |
PBM Notice to Post (Korean)
|
| Powiadomienie Dotyczące Świadczeń Farmaceutycznych W Ramach Odszkodowania Pracowniczego |
PBM Notice to Post (Polish)
|
| УВЕДОМЛЕНИЕ ОТНОСИТЕЛЬНО ФАРМАЦЕВТИЧЕСКИХ ЛЬГОТ ПРИ ПРОИЗВОДСТВЕННЫХ ТРАВМАХ |
PBM Notice to Post (Russian)
|
| 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:
|
| 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:
|
| 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:
|
| 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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