Employers Report Of Injured Employees Change In Employment Status Resulting From Injury {C-11} | Pdf Fpdf Doc Docx | New York

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Employers Report Of Injured Employees Change In Employment Status Resulting From Injury {C-11} | Pdf Fpdf Doc Docx | New York

Employers Report Of Injured Employees Change In Employment Status Resulting From Injury {C-11}

This is a New York form that can be used for Workers Compensation.

Alternate TextLast updated: 4/13/2015

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STATE OF NEW YORK WORKERS' COMPENSATION BOARD EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE IN EMPLOYMENT STATUS RESULTING FROM INJURY This report is to be filed directly with the Chair, Workers' Compensation Board at the address shown on reverse side as soon as the employment status of an injured employee, as reported on First Report of Injury, or on a previous Form C-11 or EC-11, is changed. Change in employment status includes return to work, discontinuance of work, increase or decrease of regular hours of work and increase or reduction of wages. A copy should also be sent to your insurance carrier. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. Claimant's Soc. Sec. No. Name 6. Injured Person 7. Employer Address to which notice should be sent (Give Number and Street, City, State, and Zip Code) Apt.No. 8. Carrier 9. Date of most recent Employer's Report filed:(check "x" & give date filed) First Report of Injury C-11/EC-11 10. Date of first full day employee lost from work: ___________________________ 11. Nature of Injury:_________________________ asdfas __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 12. Date employee returned to work: __________________________________ 13. (a) Change of employment status resulting from above injury: Employment Status Prior To Injury Changed To Hours per Day Days per Week Earnings Occupation (b) Date of this change in employment status:____________________ (c) Remarks:____________________________________ ______________________________________________________________________________________________________ 14. Loss of time resulting from above injury since first return to work: From (Mo., Day, Year) To (Mo., Day, Year) Reason 15. Is injured person still under physician's care?______ If yes, give name of physician:______________________________________ 16. Has injured person died?_______ If yes, give date of death:_____________________________ Name and address of nearest known relative:_____________________________________________________________________ Date of this Report_________________ Tel. No.______________________Firm Name___________________________________ Prepared By:_________________________________________ Official Title____________________________________________ C-11 (1-11) C-11 C-11 C-11 C-11 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO THE EMPLOYERS Reports should be sent directly to the Workers' Compensation Board: New York State Workers' Compensation Board PO Box 5205 Binghamton, NY 13902-5205 Statewide Fax Line: 877-533-0337 www.wcb.ny.gov THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. C-11 (1-11) Reverse American LegalNet, Inc. www.FormsWorkFlow.com

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