C-11 (6-17)
www.wcb.ny.gov
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES
PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE
IN EMPLOYMENT STATUS RESULTING FROM INJURY
C-11
PO Box 5205, Binghamton, NY 13902-5205
Fax #: (877)-533-0337
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Web Upload Link: https://wcbdoc.xrxfs.com/login.aspx
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Email Filing: wcbclaimsfiling@wcb.ny.gov
This report is to be filed directly with the Chair, Workers' Compensation Board 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 insurer.
Claim Information - ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS
Insurer ID (W#):
Social Security #:
Employee Information
Last Name: First Name: MI:
Daytime phone #:
Mailing Address: Line 2:
City: State: Zip Code: Country:
Employer Information
Employer Name:
Mailing Address: Line 2:
City:
Employer Phone #:
State: Zip Code:
Country:
Insurer Information
Insurer Name:
Mailing Address: Line 2:
City: State: Zip Code:
Country:
Email Address:
Gender:
Date of Birth:
Male
Female
SSN EIN
The Tax ID # is the
(check one):
Federal Tax ID #:
Insurer Phone #:
Date of Injury/Illness:
WCB Case #:
Claim Administrator Claim (Carrier Case) #:
Date of first full day employee lost from work: Date employee first returned to work:
Loss of time resulting from the above injury since initial date of lost time or last C-11 filed with the Board:
Loss of Time
Start Date
Return To Work Date
Reason
As a result of the above injury, was there an increase or decrease in hours worked or wages paid?
Yes No
If yes, enter status of change below:
Employment Status Effective Date Hours per Day
Days per
Week
Earnings Remarks
Prior to Injury
Changed To
An employer or insurer, or any employee, agent, or person acting on behalf of an employer or insurer, who KNOWINGLY MAKES A FALSE STATEMENT OR
REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the
purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
Prepared By:
First Name:Last Name: MI:
Employer Name:
Official Title: Phone #:
Email Address: Date of this report:
