New York State Workers' Compensation Board Forms

This form is used for political subdivisions or fire districts in New York to notify their election to secure compensation as a self-insure.

This form is used for claiming benefits in case of the death of a volunteer firefighter in New York.

This Form is used for updating the records of self-insurers in the state of New York.

This form is used for obtaining a waiver agreement in New York for Italian individuals under Section 32 of the Workers' Compensation Law.

This Form is used for asserting rights in New York, available in both English and Spanish.

New York State entities who want to be exempted from liability to carry their workers' compensation or disability benefits insurance may use this form to apply for the exemption.

This form is used by employers in New York to report work-related injuries or illnesses suffered by their employees. It is a required document for reporting such incidents for record-keeping and insurance purposes.

This Form is used for the Schedule Loss of Use - Stipulation Attachment in the state of New York. It is a document that is part of the workers' compensation process and is used to outline the specifics of a stipulation agreement regarding the loss of use of a body part.

This form is used for providing medical proof of a change in condition in support of an application to reopen a claim for workers' compensation, volunteer fire fighters' or volunteer ambulance workers' benefits in New York.

This form is used for recording job search efforts and contacts made by a claimant in New York. It is a document that helps individuals seeking unemployment benefits to maintain a detailed record of their job search activities.

This form is used for recording and documenting a claimant's job search efforts and contacts in the state of New York. It is available in Bengali language for the convenience of Bengali-speaking individuals.

This form is used for electronically signing documents in the state of New York.

This Form is used for the self-insurer's annual report for calendar year in New York.

This form is used for submitting a cover sheet that lists itemized medical bills related to a controverted World Trade Center case in New York.

This Form is used for registering efforts and contacts related to the job search of an applicant in New York.

This form is used for recording job search efforts and contacts for claimants in New York who speak Haitian Creole.

This document is for New York employees who need to file a claim and it is available in Haitian Creole.

This form is used for Korean-speaking claimants in New York to record their job search efforts and contacts.

This Form is used for employees in New York to file a claim for certain benefits. It provides instructions on how to properly fill out and submit Form C-3.

This form is used for submitting the attending ophthalmologist's report in New York.

This Form is used for attending doctors in New York to request authorization and for insurance companies to respond to their requests.

This Form is used for providing employer identification information in accordance with New York's Disability Benefits Law.

This form is used for employers in New York to apply for voluntary disability and paid family leave coverage for employees who are not required by law to have these benefits. The application requires an employee contribution.

This document is used for affirming the supervision of a physician in the state of New York. It verifies that a physician is overseeing the work of another healthcare professional.

This Form is used for self-insurers in New York to apply for a Certificate of Excess Insurance Contract. It verifies that the self-insurer has excess insurance coverage in place to cover any claims that exceed their self-insured amounts.

This form is used for applying for a license to represent insurers and self-insurers in New York.

This document is used for reporting on a patient's psychological evaluation by an attending psychologist in the state of New York.

This Form is used for notifying and providing evidence of disability benefit claims in New York. (Spanish)

This form is used for Russian-speaking employees in New York to submit a claim for compensation.

This Form is used for Polish employees in New York to file a claim for workplace injury or illness.