Form ADR-1 "Report of Work-Related Injury or Occupational Disease" - New York

What Is Form ADR-1?

This is a legal form that was released by the New York State Workers' Compensation Board - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2022;
  • The latest edition provided by the New York State Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ADR-1 by clicking the link below or browse more documents and templates provided by the New York State Workers' Compensation Board.

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Download Form ADR-1 "Report of Work-Related Injury or Occupational Disease" - New York

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PO Box 5205, Binghamton, NY 13902-5205
State of New York - Workers' Compensation Board
www.wcb.ny.gov
REPORT OF WORK-RELATED INJURY OR
OCCUPATIONAL DISEASE
This form is to be filed with the Workers' Compensation Board within 10 days of a work-related injury or
illness. A copy of this report should be provided to your insurance carrier. No hearing will be scheduled
at the Board in response to this report of injury.
EMPLOYER'S NAME AND MAILING ADDRESS
INSURANCE CARRIER'S NAME AND MAILING ADDRESS
FILING ENTITY:
Employer
Carrier
Other (If "Other", give name and address.)
CARRIER ID NUMBER
CARRIER CASE NUMBER
W-
WC POLICY NUMBER
EFFECTIVE DATE OF POLICY
INJURED EMPLOYEE (First Name, Middle Initial, Last Name)
EMPLOYEE'S ADDRESS (Street No. & Name, Apt No., City, State & Zip Code)
UNION NAME & LOCAL NUMBER
EMPLOYEE'S SOCIAL SECURITY NUMBER
DATE OF BIRTH
TELEPHONE NUMBER
GENDER
M
F
X
SPECIFIC DETAILS AS TO OCCURRENCE OF INJURY AND PART(S) OF BODY AFFECTED
ADDRESS WHERE INJURY OCCURRED
DATE OF INJURY
TIME OF INJURY
DATE SUPERVISOR FIRST KNEW OF INJURY
WAS MEDICAL CARE PROVIDED?
YES
NO
IF YES, BY WHOM?
DATE(S) MEDICAL CARE PROVIDED: _________________________________________________________________________________________
IS THIS A DEATH CASE?
YES
NO
HAS EMPLOYEE RETURNED TO WORK?
YES
NO
IF YES, DATE OF RETURN: ________/________/________
Prepared by
Official Title
Date of this Report
Telephone Number & Extension
ADR-1
ADR-1
ADR-1
ADR-1
ADR-1
SEE FILING INSTRUCTIONS
Prescribed by Chair
THE WORKERS' COMPENSATION BOARD
(6-22)
Workers' Compensation Board
EMPLOYS AND SERVES PEOPLE WITH
ON REVERSE
State of New York
DISABILITIES WITHOUT DISCRIMINATION.
PO Box 5205, Binghamton, NY 13902-5205
State of New York - Workers' Compensation Board
www.wcb.ny.gov
REPORT OF WORK-RELATED INJURY OR
OCCUPATIONAL DISEASE
This form is to be filed with the Workers' Compensation Board within 10 days of a work-related injury or
illness. A copy of this report should be provided to your insurance carrier. No hearing will be scheduled
at the Board in response to this report of injury.
EMPLOYER'S NAME AND MAILING ADDRESS
INSURANCE CARRIER'S NAME AND MAILING ADDRESS
FILING ENTITY:
Employer
Carrier
Other (If "Other", give name and address.)
CARRIER ID NUMBER
CARRIER CASE NUMBER
W-
WC POLICY NUMBER
EFFECTIVE DATE OF POLICY
INJURED EMPLOYEE (First Name, Middle Initial, Last Name)
EMPLOYEE'S ADDRESS (Street No. & Name, Apt No., City, State & Zip Code)
UNION NAME & LOCAL NUMBER
EMPLOYEE'S SOCIAL SECURITY NUMBER
DATE OF BIRTH
TELEPHONE NUMBER
GENDER
M
F
X
SPECIFIC DETAILS AS TO OCCURRENCE OF INJURY AND PART(S) OF BODY AFFECTED
ADDRESS WHERE INJURY OCCURRED
DATE OF INJURY
TIME OF INJURY
DATE SUPERVISOR FIRST KNEW OF INJURY
WAS MEDICAL CARE PROVIDED?
YES
NO
IF YES, BY WHOM?
DATE(S) MEDICAL CARE PROVIDED: _________________________________________________________________________________________
IS THIS A DEATH CASE?
YES
NO
HAS EMPLOYEE RETURNED TO WORK?
YES
NO
IF YES, DATE OF RETURN: ________/________/________
Prepared by
Official Title
Date of this Report
Telephone Number & Extension
ADR-1
ADR-1
ADR-1
ADR-1
ADR-1
SEE FILING INSTRUCTIONS
Prescribed by Chair
THE WORKERS' COMPENSATION BOARD
(6-22)
Workers' Compensation Board
EMPLOYS AND SERVES PEOPLE WITH
ON REVERSE
State of New York
DISABILITIES WITHOUT DISCRIMINATION.
FILING INSTRUCTIONS
Please note that the ADR-1 Report of Injury form must be submitted to the
Workers' Compensation Board within 10 days of a work related injury or
illness, as required by 12 NYCRR § 314.2(d)(5).
The ADR-2 Final Disposition of Claim form must be filed with the Workers'
Compensation Board's local district office within 30 days of the final
resolution of a claim through settlement, mediation,or arbitration, as
required by 12 NYCRR § 314.7(a).
Failure to
the prescribed ADR forms with the Workers' Compensation
file
Board in a timely manner may
in revocation of the parties'
result
authorization to
in the Alternative Dispute Resolution
participate
Pilot
Program.
ADR-1 (6-22) Reverse
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