- ADR Program Final Disposition Of Claim {ADR-2}
- Affirmation For Death Benefits {AFF-1}
- Affirmation For License To Operate An X-Ray Bureau Or Laboratory {C-100.2}
- Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only) {C-312.5}
- Application Agreement Plan Of Association - Disability And-Or Family Leave {DB-801}
- Application For A Fee By Claimants Attorney Or Representative {OC-400.1}
- Application For Acceptance Of Insurance Form {DB-850}
- Application For Board Review {RB-89}
- Application For License To Represent Insurers And Or Self-Insurers {OC-403}
- Application For Plan Of Employer - Disability And-Or Family Leave {DB-800}
- Application For Reconsideration Full Board Review {RB-89.2}
- Application For Reopening Of Claim More Than Seven Years After Accident {C-25}
- Attachment For Report Of Ind Med Exam Non Scheduled Perm Partial Disability {IME-4.3B}
- Attachment For Report Of Independent Med Exam Scheduled Loss Of Use {IME-4.3A}
- Attorney-Licensed Representative Request To Withdraw From Representation {OC-400.17}
- Attorney-Representatives Certification Of Form C-3 Or Notice Of Controversy {OC-400.5}
- Biannual Recertification To Entitlement To Benefits {DD-2}
- Carriers Or Self-Insured Employers Affirmation {C-32AF}
- Carriers Report On Rehabilitation To Chair Workers Compensation Board {R}
- Carriers Request Benefit Increase Reimbursement Under VF-VAW Benefit Laws {VF-VAW-10}
- Carriers Request For Reimbursement Of Compensation Payments Under Section 14(6) (Blue Paper) {C-251.2}
- Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper) {C-251.1}
- Claim For Compensation And Notice Of Commencement Of Third Party Action {C-121}
- Claim For Compensation In Death Case {C-62}
- Claim For Volunteer Ambulance Workers Benefits In A Death Case {VAW-62}
- Claim For Volunteer Firefighters Benefits In A Death Case {VF-62}
- Claimants Authorization To Disclose Workers Compensation Records (Autorizacion Del Reclamante - Spanish) {OC-110A}
- Claimants Authorization To Disclose Workers Compensation Records {OC-110A}
- Claimants Notice Of Independent Medical Examination {IME-5}
- Claimants Record Of Independent Job Search Efforts {C-258.1}
- Claimants Record Of Job Search Efforts Contacts {C-258}
- Claimants Record Of Medical And Travel Expenses And Request For Reimbursement {C-257}
- Claimants Statement Regarding No Fault Or Personal Injury {DB-450.1}
- Consent To NYS WCB Jurisdiction For Non-NY Carriers (3C Coverage) {C-105.11}
- Cover Sheet-List Of Itemized Medical Bills In Controverted World Trade Center Case {WTC-16}
- Direct Deposit Authorization Form {DD-1}
- Disability Benefits Law Employer Identification Information {DB-125}
- Discharge Or Discrimination Complaint {DC-120}
- Doctors Report Of MMI-Permanent Impairment {C-4.3}
- Electronic Attachment
- Employee Claim {C-3}
- Employees Statement Of Exempt Status {DB-130}
- Employer Whistleblower Form {CE-150-RF}
- Employers Application To Have Association Union Or Trustee Plan Accepted As Employers Plan {DB-802}
- Employers Application Voluntary For Employees Benefits Not Required (Employee Contrib) {DB-136}
- Employers Application Voluntary For Employees Benefits Not Required (No Contrib) {DB-135}
- Employers First Report Of Work-Related Injury Or Illness {C-2F}
- Employers Report Of Injured Employees Change In Employment Status Resulting From Injury {C-11}
- Employers Statement For Purpose Of Terminating Status As Covered Employer {DB-118}
- Employers Statement Of Wage Earnings (Preceding Date Of Injury-Illness) {C-240}
- Extreme Hardship Redetermination Request {C-35}
- Health Insurers Request For Reimbursement {HIMP-1}
- Impartial Specialists Report Of Medical Records Review {MR-4}
- Independent Examiners Report of Independent Medical Examination {IME-4}
- Independent Examiners Report Of Request For Information Or Response To Request Regarding Ind Med Exam {IME-3}
- Initial Application To Take License Rep Exam To Appear On Behalf Of Claimants Or To Represent Carriers-Self-Insurers {OC-409}
- Insurers Notification Of Initial Request For Reimbursement 14(6) Or 15(8) {C-251N}
- Insurers Request For Reconsideration Of Reduction Under WCL § 14(6) Or 15(8) {C-251.6}
- Insurers Request For Reimbursement Of Medical Payments WCL Section 15(8) {C-251.1}
- Licensed Representatives Disclosure Of Conflict Of Interest To Client {OC-408}
- Limited Release Of Health Information (HIPAA) {C-3.3}
- Loss Of Wage Earning Capacity Vocational Data Form {VDF-1}
- Medical Proof Of Change Re Application For Reopening Claim {C-27}
- Modification Of Previous Report (ADR Program) {ADR-1.1}
- Notice And Proof Of Claim For Disability Benefits {DB-450}
- Notice Of Election Corporation Exclude Sole Shareholder Officers Shareholders From WC {C-105.51}
- Notice Of Election Municipal Corporation Other Political Subdivision Bring Executives Under NY WC {C-105.31}
- Notice Of Election Nonprofit To Exclude Unsalaried Executive Officer From WC {C-105.52}
- Notice Of Election Of Corporation To Exclude Shareholder Officers From Disability Coverage {DB-212.3}
- Notice Of Election Provide WC To Participants In Sheltered Workshop {C-105.54}
- Notice Of Election Religious Charitable Organization Bring Executives Under NY WC {C-105.3}
- Notice Of Election To Bring Partners Or Self Employed Under NY WC {C-105.32}
- Notice Of Election To Voluntarily Exclude Spouse From Coverage {DB-212.5}
- Notice Of Insurers Refusal To Pay Medical Bill Valuation Objections {C-8.4}
- Notice Of Objection To Payment Of Bill For Treatment Provided {C-8.1B}
- Notice Of Retainer And Appearance On Behalf Of Employer {OC-406}
- Notice Of Retainer And Appearance Or Notice Of Substitution And Appearance {OC-400}
- Notice Of Right To Reimbursement Of Compensation Payments {C-251.3}
- Notice Of Right To Select Workers Compensation Board Authorized Health Care Provider {C-3.1}
- Notice That Claimant Must Arrange For Diagnostic Tests And Examinations Through Network Provider {DT-1}
- Notice That You May Be Responsible For Medical Costs {A-9}
- Notice To Chair Of Withdrawal Of Request For Arbitration {HP-4}
- Notice To Liable Political Subdivision Of Volunteer Firefighters Injury Or Death {VF-1}
- Notice To Liable Political Subdivision Or Unaffiliated Ambulance Service {VAW-1}
- Occupational Injury-Illness Statement Of Rights {C-430S}
- Paid Family Leave Supplement To Certificate Of Insurance {PFL-820.1}
- Physicians Application For Designation As Impartial Specialist {IS-1}
- Physicians Application For Renewal Of Designation As Impartial Specialist {IS-1R}
- Practitioners Report Of Functional Capacity Evaluation {FCE-4}
- Pre Hearing Conference Statement {PH-16.2}
- Proof Of Burial And Funeral Expenses By Undertaker {C-65}
- Proof Of Death By Physician Last In Attendance On Deceased {C-64}
- Providers Request For Judgment Of Award {HP-J1}
- Rebuttal Of Application For Board Review {RB-89.1}
- Rebuttal Of Application For Reconsideration Full Board Review {RB-89.3}
- Reclamacion Del Empleado {C-3S}
- Record Of Percentage Hearing Loss {C-72.1}
- Registration Of Participation In WTC Rescue Recovery Clean-Up Operations {WTC-12}
- Renewal Application For License To Appear On Behalf Of Claimant {OC-401.1R}
- Report Of Impartial Specialist Examination Or Record Review {IS-4}
- Report Of Work-Related Injury Or Occupational Disease {ADR-1}
- Request For Assistance By Injured Worker {RFA-1W}
- Request For Further Action By Insurer-Employer {RFA-2}
- Request For Further Action By Legal Counsel {RFA-1LC}
- Request For Judicial Order - Access To Case Files {OC-110AORD}
- Revocation Of Election Corporation Exclude Sole Shareholder Officer From WC Coverage {C-105.55}
- Revocation Of Election Municipal Corporation Other Political Subdivision Bring Executives Under NY WC {C-105.41}
- Revocation Of Election Nonprofit Or Unincorporated Assoc To Exclude Unsalaried Officer From WC {C-105.53}
- Revocation Of Election Religious Charitable Organization Bring Executives Under NY WC {C-105.4}
- Section 32 Electronic Signature {C-32E}
- Section 32 Waiver Agreement Claimant Release {C-32.1}
- Self Insurers Representatives Bond {OC-407}
- Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement {C-32-I}
- Sexual Harassment Policy
- Sexual Harassment Prevention Poster
- Statement Of Registration Section 13n-WCL IME Entity {IME-7}
- Statement Of Unresolved Issues-Special Part For Expedited Hearings {C-300.34}
- Stipulation {C-300.5}
- Supplement To Certificate Of Insurance {DB-820.1}
- Unemployment – Record of Employment
- Volunteer Ambulance Workers Claim For Benefits {VAW-3}
- Volunteer Firefighters Claim For Benefits {VF-3}
- Volunteers Notification Of Exec Officer Fire-Ambulance Company-Significant Risk Of HIV {VF-VAW-11C}
- Waiver Agreement - Section 32 WCL {C-32}pdf
- World Trade Center September 11th Victim Compensation Fund Authorization {WTC-VCF-AUTH}
- World Trade Center Volunteer HIPAA Authorization {WTC-HIPAA}
- World Trade Center Volunteers Claim For Compensation {WTC Vol-3}