New York State Workers' Compensation Board Forms

This form is used for requesting a redetermination of extreme hardship in New York. It is used when individuals believe their circumstances have changed since their initial extreme hardship determination.

This form is used for reporting and resolving treatment or disputed bill issues in New York.

This Form is used for providing proof of death by the last physician who attended to the deceased in the state of New York.

This form is used for recording and documenting the independent job search efforts of individuals filing a claim in New York.

This Form is used for filing a claim for compensation and providing notice of a third-party action in the state of New York. It is used to seek compensation and commence legal action against a third party for a personal injury or property damage.

This Form is used for creating a legal agreement between parties in New York. It outlines the terms and conditions that have been agreed upon.

This form is used for notifying the election to voluntarily exclude a spouse from coverage under the NYS Disability and Paid Family Leave Benefits Law in New York.

This form is used to notify the election of a corporation in New York to exclude certain shareholders or officers from disability and paid family leave benefits coverage.

This form is used for employers in New York to terminate their status as a covered employer.

This form is used for claimants in New York to provide a statement about no fault or personal injury.

This form is used for applying for acceptance of insurance under Section 360.1(B)(1) of NYCRR in New York.

This form is used for the New York State Workers' Compensation Board Health Insurance Matching Program in New York. It is a program that helps individuals with workers' compensation benefits to receive health insurance coverage.

This document is used for attaching additional information to the Report of Independent Medical Examination for non-scheduled permanent partial disability in New York.

This form is used for attaching a report of an independent medical examination for scheduled loss of use in New York.

This Form is used for claimants in New York to give notice of their independent medical examination.

This form is used for reporting the results of an independent medical examination conducted by an independent examiner in New York.

This form is used for requesting a judicial order in New York to gain access to case files.

This document is used as a continuation to Form MG-1 for New York. It is a request form from the attending doctor for optional prior approval.

This Form is used for attending doctor's to request optional prior approval and for carrier's/employer's response in New York.

This Form is used for physicians in New York to apply for the renewal of their designation as an impartial specialist.

This form is used for requesting approval of a variance by the attending doctor in New York.

This form is used for claimants in New York to authorize the disclosure of their workers' compensation records.

This form is used for requesting approval of variance and the carrier's response in the state of New York.

This form is used for notifying a court or legal entity of the retention and appearance of legal representation on behalf of an employer in the state of New York.

This form is used for licensed representatives in New York to disclose any conflicts of interest they may have to their clients. It ensures transparency in the client-advisor relationship.

This form is used for providing additional information and details to a Certificate of Insurance in the state of New York. It is a supplement form that helps to expand on the coverage and terms mentioned in the original certificate.

This form is used for submitting a pre-hearing conference statement in New York. It is required before a hearing to provide information and discuss the case with the court.