Fillable New York Workers' Compensation Claimant Information Packet

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New York Workers' Compensation Claimant Information Packet

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THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
NEW YORK STATE
WORKERS’ COMPENSATION BOARD
100 BROADWAY-MENANDS
ALBANY, NY 12241
(877) 632-4996
You were injured at work. What now?
The New York State Workers’ Compensation Board has received notice you suffered a
workplace injury or illness, so we’re preparing a workers’ compensation case in your
name. You may have already received medical treatment. If you haven’t, you should
seek medical care as soon as possible.
A Worker’s Responsibilities
You must tell your employer, in writing, when, where and how you were injured. Do
this within 30 days of injury.
Medical reports are necessary for your case. Advise your doctors that you have a
work-related injury, and give the name of your employer. Do not pay for your care
yourself or use other health insurance. Tell your doctor to file reports with the Board
and with your employer or its insurance carrier. If your case is disputed, the Board
needs a medical report on your injury to begin resolving your claim.
Starting a Case
Once your employer knows of your injury, it must notify this Board. You should file an
employee claim (C-3 form) reporting your injury as soon as possible. (You must notify
the Board of your injury or illness within two years.) If you injured the same body part
before, or had a similar illness, you must also file a Form C-3.3.
If you haven’t already filed a C-3 or C-3.3 (if necessary), there are three ways to do it.
Visit www.WCB.NY.Gov and click Workers to complete the form.
Call 1-866-396-8314. A Board employee will complete the form with you.
Complete the enclosed paper forms and mail them to the Board.
Health Care Bills
Do not pay your doctor or hospital. Those bills are paid by the insurer unless the Board
disallows your case. If your case is disputed, the providers are paid when the Board
decides your case. If the Board decides against you, or if you don’t pursue a case, you
will have to pay the doctor or hospital.
Your employer’s insurance covers medically necessary drugs and equipment your
doctor prescribes. You’re also entitled to carfare or necessary expenses incurred when
traveling for treatment. (Get receipts for those expenses.)
Claimant Information Packet
NEW YORK STATE WORKERS' COMPENSATION BOARD
Generally, you can choose any doctor authorized by the Board. You can also use
occupational health clinics. However, if your employer’s insurer has a preferred provider
organization to provide care for workers' compensation injuries, you must get your initial
treatment from those providers. If that insurer also has a pharmacy or diagnostic
network, you must get service within these networks. If the carrier uses these networks,
it must also tell you its service providers and how to use them.
Benefits for Lost Wages
You are entitled to a portion of your lost wages if your injury affects you in one or more
ways:
1. It keeps you from work for more than seven days;
2. Part of your body is permanently disabled;
3. Your pay is reduced because you now work fewer hours or do other work.
An employer or insurer can accept your claim and begin paying your lost wage benefit
promptly. Sometimes, employers and carriers dispute a claim. When that occurs, the
Board strives to resolve most cases within 90 days.
You may hire an attorney or licensed representative, who can be helpful with complex
or disputed claims, but it isn’t required. The Board sets their fees and they will be
deducted from your lost wages award. You or your family should not pay anything
directly to your attorney or licensed representative.
If your case is disputed, you may receive disability benefits while the case is heard.
You’d pay them back out of your lost wages award. To get a DB-450 form, visit
www.wcb.ny.gov and click Workers; visit a Board office; or call (800) 353-3092.
Help is Available
People sometimes need help getting back to work. Your employer may have a return to
work program that can get you back to work in light duty or an alternative position while
you heal. An injury can also cause family or financial problems. The Workers'
Compensation Board has rehabilitation counselors and social workers to help. Call
(877) 632-4996 for more assistance.
What’s Next?
Your employer or its insurance carrier will contact you if your claim is accepted. When
that happens, your treatment will be paid and lost wage benefits begin. If your case is
challenged, the Board will notify you about resolving the case. If more information is
necessary, the Board will contact you and tell you how to file it.
Important Contact Information
Workers’ Compensation Board
(877)632-4996
Disability Benefits
(800)353-3092
NYS Bar Association Lawyer
Referral and Information Service
(800)342-3661
Employee Claim
State of New York - Workers' Compensation Board
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE
WITH DISABILITIES WITHOUT DISCRIMINATION
C-3
Number and Street City State Zip Code
B. YOUR EMPLOYER(S)
1. Employer when injured:
3. Your work address:
6. List names/addresses of any other employer(s) at the time of your injury/illness:
7. Did you lose time from work at the other employment(s) as a result of your injury/illness?
NoYes
Female
A. YOUR INFORMATION (Employee)
1. Name:
3. Mailing address:
4. Social Security Number:
6. Gender:
Male
C. YOUR JOB on the date of the injury or illness
1. What was your job title or description?
2. What types of activities did you normally perform at work?_________________________________________________________________
3. Was your job? (check one)
Full Time Part Time Seasonal Volunteer Other:____________________
4. What was your gross pay (before taxes) per pay period?
5. How often were you paid?
Yes
6. Did you receive lodging or tips in addition to your pay?
If yes, describe:
No
D. YOUR INJURY OR ILLNESS
3. Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)
If no, why were you at this location?
NoYes
4. Was this your usual work location?
5. What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report) _______________________________
WCB Case Number (if you know it):
Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type or
print neatly. This form may also be filled out on-line at www.wcb.ny.gov.
Number and Street/PO Box City State Zip Code
7. Will you need a translator if you have to attend a Board hearing?
Yes No
If yes, for what language?
6. How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)
7. Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):______________________
First MI Last
5. Your supervisor's name:
2. Date of Birth: ______/______/______
5. Phone Number: (_____)_______________
2. Phone Number: (_____)_______________
4. Date you were hired: _____/_____/_____
1. Date of injury or date of onset of illness: ______/______/______
AM PM
2. Time of injury:
www.wcb.ny.gov
C-3.0 (1-11) Page 1 of 2
- -
No
No
D. YOUR INJURY OR ILLNESS continued
If yes, what?
No
Yes 8. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?
9. Was the injury the result of the use or operation of a licensed motor vehicle?
If yes,
your vehicle
employer's vehicle other vehicle
License plate number (if known):
If your vehicle was involved, give name and address of your motor vehicle insurance carrier:
10. Have you given your employer (or supervisor) notice of injury/illness?
in writing
orally
If yes, notice was given to: ____________________________________
11. Did anyone see your injury happen?
If yes, list names:________________________________________
F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS
None received (skip to question F-5)
3. Where did you receive your first off site medical treatment for your injury/illness?
none received
Doctor's office
Emergency Room
Clinic/Hospital/Urgent Care Hospital Stay over 24 hours
Name and address where you were first treated:
4. Are you still being treated for this injury/illness?
Give the name and address of the doctor(s) treating you for this injury/illness:
5. Do you remember having another injury to the same body part or a similar illness?
6. Was the previous injury/illness work related?
If yes, were you working for the same employer that you work for now?
NoYes
NoYes
Yes
NoYes
No Yes
NoYes
Yes
An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.
I am hereby making a claim for benefits under the Workers' Compensation Law. My signature affirms that the information I am providing is true
and accurate to the best of my knowledge and belief.
Employee's Signature: Print Name:
On behalf of Employee: Print Name:
If yes, were you treated by a doctor?
NoYes
If yes, provide the names and addresses of the doctor(s) who treated
you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM:
Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it
will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any
material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.
YOUR NAME:________________________________________________ DATE OF INJURY/ILLNESS: ______/______/______
Date notice given: _____/_____/_____
limited duty
E. RETURN TO WORK
1. Did you stop work because of your injury/illness?
2. Have you returned to work?
regular duty
3. If you have returned to work, who are you working for now?
Same employer
New employer
Self employed
4. What is your gross pay (before taxes) per pay period?
How often are you paid?
NoYes
NoYes
, on what date? _____/_____/_____ , skip to Section F.
If yes, on what date? _____/_____/_____
Date: _____/_____/_____
Date: _____/_____/_____
1. What was the date of your first treatment? ______/______/______
2. Were you treated on site?
Yes No
Phone Number: (_____)_______________
Phone Number: (_____)_______________
Unknown
First MI Last
C-3.0 (1-11) Page 2 of 2
I certify to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the allegations and other factual
matters asserted above have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery.
Signature of Attorney/Representative (if any):
Print Name:
Title:
ID No., if any: R
Date: _______/_______/_______
If Licensed Representative, License No.:
Expiration Date: _______/_______/_______
www.wcb.ny.gov
C-3.3 (12-09)
Limited Release of Health Information
(HIPAA)
State of New York - Workers' Compensation Board
C-3.3
WCB Case No. (if you know it):___________________________
To Claimant: If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current
Claim, fill out this form. This form allows the health care providers you list below to release health care information about your previous injury/
illness to your employer's workers' compensation insurer. The federal HIPAA law (Health Insurance Portability and Accountability Act of 1996)
says you have a right to get a copy of this form. If you do not understand this form, talk to your legal representative. If you do not have a legal
representative, the Advocate for Injured Workers at the Workers' Compensation Board can help you. Call: 800-580-6665.
To Health Care Provider: A copy of this HIPAA-compliant release allows you to disclose health information. If you send records to the
employer's workers' compensation insurer in response to this release, also mail copies to the Claimant's legal representative. (If no legal
representative is listed below, send copies to the Claimant.) Health care providers who release records must follow New York state law and
HIPAA.
This release is:
Voluntary. Your health care provider(s) must give you the same care,
payment terms, and benefits, whether you sign this form or not.
Limited. It gives your health care provider(s) permission to release only
those health records that are related to the previous illness/condition you
describe below.
Temporary. It ends when your current claim for compensation is established
or disallowed and all appeals are exhausted.
Revocable. You can cancel this release at any time. To cancel, send a letter
to the health care provider(s) listed on this form. Also, send a copy of your
letter to your employer's workers' compensation insurer and the Workers'
Compensation Board. Note: You may not cancel this release with respect to
medical records already provided.
For records only. It gives your health care provider(s) listed on this form
permission to send copies of your health care records to your employer's
workers' compensation insurer.
This form does NOT allow your health care provider(s)
to release the following types of information:
HIV-related information
Psychotherapy notes
Alcohol/Drug treatment
Mental Health treatment (unless you check below)
Verbal information (your health care providers may
not discuss your health care information with anyone)
Any medical records released will become part of your workers' compensation file and are confidential under the Workers' Compensation Law.
A. YOUR INFORMATION (Claimant)
1. Name:__________________________________________________________________ 2. Social Security Number:______-_____-______
3. Mailing Address: _________________________________________________________________________________________________
4. Date of Birth: ______/______/______ 5. Date of the current injury/illness: ______/_______/_______
6. Current injury/illness, including all body parts injured:_____________________________________________________________________
______________________________________________________________________________________________________________
7. Your legal representative's name and address (if any):___________________________________________________________________
______________________________________________________________________________________________________________
Check here if you allow your health care provider(s) to release mental health care information.
B. YOUR HEALTH CARE PROVIDER(S) (List all health care providers who treated you for a previous injury to the same body part or similar
illness. If more than 2 providers attach their contact information to this form.)
1. Provider:__________________________________________________________________ 2. Phone Number: (______)_______________
3. Mailing Address: _________________________________________________________________________________________________
4. Other provider (if any):_______________________________________________________ 5. Phone Number: (______)_______________
6. Mailing Address:_________________________________________________________________________________________________
C. READ AND SIGN BELOW. I hereby request that the health care provider(s) listed above give my employer's workers' compensation
insurer copies of all health records related to any previous injury/illness, to all body parts, described above.
____________________________________________________________________________________________________________
If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below:
______________________________________________________________________________________________________________
Claimant's signature (ink only -- use blue ballpoint pen, if possible.) Date
Your name Relationship to Claimant Signature (ink only -- use blue ballpoint pen, if possible.) Date
Versión en español al reverso de la forma.
www.wcb.ny.gov
C-3.3 (12-09)
WCB Case No. (if you know it) (Número de caso WCB [si lo sabe])
Divulgación limitada de información sobre la salud
(HIPAA)
Estado de NuevaYork - Junta de Compensación Obrera (WCB)
C-3.3
Al reclamante: Si usted recibió tratamiento por una lesión anterior en la misma parte del cuerpo o por una enfermedad similar a la que motiva
ahora su reclamación, complete este formulario. Este formulario les permite a los proveedores de salud que usted señala a continuación divulgar
a la compañía de seguros de compensación obrera de su empleador la información sobre su salud relacionada con su lesión/enfermedad
anterior. La Ley federal HIPAA (Ley de portabilidad y responsabilidad del seguro de salud de 1996) establece que usted tiene derecho a recibir
una copia de este formulario. Si no comprende este formulario, hable con su representante legal. Si no tiene un representante legal, el
Representante de los obreros lesionados de la Junta de Compensación Obrera puede ayudarlo. Llame al 800-580-6665.
Al proveedor de salud: Una copia de esta divulgación, redactada según lo que establece la ley HIPAA, le permite divulgar información sobre la
salud. Si envía los registros al asegurador de compensación obrera del empleador en respuesta a la presente divulgación, también debe enviar
por correo copias al representante legal del reclamante. (Si a continuación no se especifica un representante legal, envíe las copias al
reclamante). Los proveedores de salud que divulgan los registros deben cumplir con las leyes del estado de Nueva York y la HIPAA.
Esta divulgación es:
Voluntaria. Su(s) proveedor(es) de salud deben otorgarle la misma
atención, condiciones de pago y beneficios, independientemente de que
usted firme este formulario o no.
Limitada. Le otorga a su(s) proveedor(es) de salud permiso para divulgar
únicamente los registros médicos que se relacionen con la enfermedad/
afección anterior que usted describe a continuación.
Temporal. Termina cuando se otorgue o desestime su actual reclamación
de compensación y se hayan agotado todas las apelaciones.
Revocable. Usted puede cancelar esta divulgación en cualquier momento.
Para hacerlo, envíe una carta al (a los) proveedor(es) de salud que se
indican en este formulario. Además, envíe una copia de su carta a la
compañía de seguros de compensación obrera de su empleador y a la Junta
de Compensación Obrera. Nota: No podrá cancelar esta divulgación en lo
que se refiere a registros médicos que ya se hayan provisto.
Solamente para registros. Le otorga a su(s) proveedor(es) de salud que se
indica(n) en este formulario permiso para enviar copias de sus registros de
salud a la compañía de seguros de compensación obrera de su empleador.
Este formulario NO autoriza a su(s) proveedor(es) de
salud a divulgar los siguientes tipos de información:
Información relacionada con el VIH
Notas de terapia psicológica
Tratamientos por abuso de alcohol o drogas
Tratamiento de salud mental (a menos que usted lo
indique a continuación)
Información verbal (sus doctores no pueden hablar
con nadie sobre su información de salud)
Los registros médicos divulgados se incorporarán a su expediente de compensación obrera y son confidenciales conforme a la
Ley de compensación obrera.
A. YOUR INFORMATION (Claimant) INFORMACIÓN PERSONAL (Reclamante)
1. Name (Nombre) 2. Social Security Number (Número de seguro social)
3. Mailing Address (Dirección postal)
4. Date of Birth (Fecha de nacimiento) 5. Date of the current injury/illness (Fecha de la lesión/enfermedad actual)
6. Current injury/illness, including all body parts injured (Descripción de la lesión/enfermedad actual, incluyendo todas las partes del
cuerpo lesionadas)
7. Your legal representative's name and address (if any) (Nombre y dirección de su representante legal [si corresponde])
Check here if you allow your health provider(s) to release mental health care information. (Marque aquí si autoriza a su(s) proveedor(es) de
salud a divulgar información sobre tratamientos de salud mental.)
B. YOUR HEALTH CARE PROVIDERS (List all health care providers who treated you for a previous injury to the same body part or similar
illness. If more than 2 providers, attach their contact information to this form.
SU(S) PROVEEDOR(ES) DE SALUD (Enumere todos los proveedores de salud que le han tratado por lesiones previas a las mismas
areas del cuerpo ó por enfermedades semejantes.Si son más de 2 proveedores, adjunte su información de contacto a este formulario.)
1. Provider (Proveedor de salud) 2. Phone Number (N
o
de teléfono)
3. Mailing Address (Dirección postal)
4. Other provider (if any) (Otro proveedor [si corresponde]) 5. Phone Number (N
o
de teléfono)
6. Mailing Adress (Dirección postal)
C
. READ AND SIGN BELOW I hereby request that the health care provider(s) listed above give my employer's workers' compensation
insurer copies of all health records related to any previous injury/illness, to all body parts, described above.
LEA Y FIRME A
CONTINUACIÓN.
Por la presente solicito que los proveedores de salud aquí enumerados le provean al asegurador de compensación
obrera de mi patrono copias de todos los records médicos relacionados a cualquier lesión/enfermedad aquí enumeradas.
If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below: (Si el reclamante no puede firmar, la
persona que firme el formulario en su nombre y representación debe llenar y firmar a continuación)
Claimant's signature (Firma del reclamante ) use solo tinta - preferiblemente azul Date (Fecha)
Your name (Su nombre) Relationship to Claimant (Relación con el reclamante) Signature(Firma) Date(Fecha)
CONTESTA LAS SIGUIENTES PREGUNTAS, EN INGLÉS SI ES POSIBLE, EN LOS ESPACIOS PROVISTOS Y FIRMA
AL FRENTE DE LA FORMA.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
C-3.0 (1-11)
Instructions for Completing Form C-3, “Employee Claim”
Please complete this form and send it to the Workers' Compensation Board centralized mailing address listed at the bottom
of these instructions. If you need additional help in completing this form, contact the Workers' Compensation Board at
1-877-632-4996. You may also fill this form out online at: http://www.wcb.ny.gov/
If you do not have or know your Workers' Compensation Board Case Number, please leave this field blank. It is not
required to process your claim. Remember to enter your name and the date of your injury/illness on the top of page
two.
Section A - Your Information (Employee):
Item 1: Enter your full name, including first name, middle initial, and last name.
Item 2: Enter your date of birth in month/day/year format. Include the four digit year.
Item 3: Enter your mailing address, including P.O. Box, if applicable, city or town, state, and Zip code.
Item 4: Enter your Social Security Number. This is very important to help service your claim faster.
Item 5: Indicate the primary contact phone number, including area code. This may include a cell phone number.
Item 6: Indicate your gender (Male or Female).
Item 7: Board hearings are conducted in English. If you will need a translator to understand the proceeding, the Board will
provide one. Check Yes and indicate the language needed.
Section B - Your Employer(s):
Item 1: Indicate the employer you were working for at the time you were injured or became ill.
Item 2: Enter the phone number for this employer, either a primary contact number or the number for your supervisor.
Item 3: Enter the employer's address, including P.O. Box, if applicable, city or town, state, and Zip code.
Item 4: Indicate the date you were hired by this employer.
Item 5: Enter your direct supervisor's name, whom you report to on a regular basis.
Item 6: If you have more than one job, please indicate the names and addresses of all other employers you work for besides
the one you were injured at. Please attach a separate sheet if you need more room.
Item 7: Check Yes if you lost time from any of your other jobs as a result of your injury or illness; otherwise, check No.
Section C - Your Job on the Date of the Injury or Illness:
Item 1: Indicate your current job title or job description (e.g., warehouse worker).
Item 2: Indicate your typical work activities for this job (e.g., keeping inventory, unloading trucks, etc.).
Item 3: Check the type of job you had.
Item 4: Enter your gross pay (before taxes) per pay period.
Item 5: Indicate how often you received a paycheck (weekly, bi-weekly, etc.).
Item 6: Indicate if you received any tips or lodging in addition to your regular pay. If you did, describe them.
Section D - Your Injury or Illness:
Item 1: Enter the date when you were injured or the first date you noticed you became ill. Enter the date in month/day/year
format. Include the four digit year. If this is an illness or occupational disease, then skip item 2.
Item 2: Enter the time when the injury occurred. Check whether it was AM or PM.
Item 3: Indicate the location where the injury/illness occurred, including the address of the building and the physical
location in the building where the injury/illness happened.
Item 4: Check whether this was your normal work location. If it was not, explain why you were at this location.
Item 5: Describe in detail what you were doing at the time of the injury/illness (e.g., unloading boxes from a truck by hand).
This explains the events leading up to the injury.
Item 6: Describe in detail how the injury/illness occurred (e.g., I was lifting a heavy box off a truck). This should include all
people and events involved in the injury/illness.
Item 7: Indicate fully the nature and extent of your injury/illness, including all body parts injured. Be as specific as possible.
(e.g., I strained my back trying to lift a heavy box. It hurts to bend over or hold even lighter objects now.)
Item 8: Indicate if some object was involved in the accident OTHER THAN a licensed motor vehicle. Other objects may
include a tool (e.g., hammer), a chemical (e.g., acid), machinery (e.g., forklift or drill press), etc.
Item 9: Indicate if a licensed motor vehicle was involved in the accident. If so, check if the motor vehicle involved was
yours, your employer's, or a third party's. Include the license plate number (if known). If your vehicle was involved,
fill out the name and address of your automobile liability insurance carrier.
Item 10: Check if you gave your employer or supervisor notice of your injury or illness. If so, indicate who you gave notice
to as well as if it was orally or in writing. Include the date you gave notice.
Item 11: Check if anyone else saw the injury happen. If anyone did see it, include their name(s).
Section E - Return to Work:
Item 1: If you stopped working as a result of your work-related injury/illness, check Yes and indicate on what date you
stopped working. If you have not stopped working, check No and skip to the next section.
Section E - Return to Work (cont):
Item 2: If you have since returned to work, check Yes. Also indicate on what date you started working again, as well as if you
have returned to your Normal Duties or if you are on Limited or Restricted Duty. (If you have not returned to your full
pre-injury or illness work duties, then you are on Limited Duty.)
Item 3: If you have returned to work, indicate who you are working for now.
Item 4: Enter your gross pay (before tax pay) per pay period for the job you are working at now. Indicate how often you are
receiving a paycheck (weekly, bi-weekly, etc.).
Section F - Medical Treatment for This Injury or Illness:
Item 1: If you did not receive medical treatment for this injury/illness, check None Received and skip to item 5. Otherwise,
enter the date you first received treatment for this injury/illness and complete the rest of this section.
Item 2: Check if you were first treated on the job for this injury or illness.
Item 3: Check the location where you first received off site medical treatment for your injury or illness. Include the name and
address of the facility as well as the phone number (including area code).
Item 4: If you are still receiving ongoing treatment for the same injury or illness, check Yes and indicate the name and
address of the doctor(s) providing treatment as well as the phone number (including area code); otherwise check No.
Item 5: If you believe you already had an injury to the same body part or a similar illness, check Yes and indicate if you were
treated by a doctor for this injury or illness. If you were treated by a doctor, indicate the name(s) and address(es) of the
doctor(s) whom provided care and complete and file Form C-3.3 together with this form.
Item 6: If you had a previous injury or illness, check if your previous injury or illness was work-related. If Yes, check if
the injury or illness happened while working for your current employer.
Sign Form C-3 in the place provided for "Employee's Signature on page 2, print your name, and enter the date you signed the
form. If a third-party is signing on behalf of the employee, that person should sign on the second signature line. If you have
legal representation, your representative must complete and sign the attorney/representative's certification section on the
bottom of page 2.
What Every Worker Should Do in Case of On-The-Job Injury or Occupational Disease:
1. Immediately tell your employer or supervisor when, where and how you were injured.
2. Secure medical care immediately.
3. Tell your doctor to file medical reports with the Board and with your employer or its insurance carrier.
4. Make out this claim for compensation and send it to the Workers' Compensation Board centralized mailing address. Failure to file
within two years after the date of injury may result in your claim being denied. If you need help in completing this form, contact the
Workers' Compensation Board at 1-877-632-4996.
5. Go to all hearings when notified to appear.
6. Go back to work as soon as you are able; compensation is never as high as your wage.
Your Rights:
1. Generally, you are entitled to be treated by a doctor of your choice, provided he/she is authorized by the Board. If your employer is
involved in a preferred provider organization (PPO) arrangement, you must obtain initial treatment from the preferred provider
organization which has been designated to provide health care services for workers' compensation injuries.
2. DO NOT pay your doctor or hospital. Their bills will be paid by the insurance carrier if your case is not disputed. If your case is
disputed,
the doctor or hospital must wait for payment until the Board decides your case. In the event you fail to prosecute your case or the
Board decides against you, you will have to pay the doctor or hospital.
3. You are also entitled to be reimbursed for drugs, crutches, or any apparatus properly prescribed by your doctor and for carfares or other
necessary expenses going to and from your doctor's office or the hospital. (Get receipts for such expenses.)
4. You are entitled to compensation if your injury keeps you from work for more than seven days, compels you to work at lower wages,
or results in permanent disability to any part of your body.
5. Compensation is payable directly and without waiting for an award, except when the claim is disputed.
6. Injured workers or dependents of deceased workers may represent themselves in matters before the Board or may retain an attorney or
licensed representative to represent them. If an attorney or licensed representative is retained, his/her fee for legal services will be
reviewed by the Board and if approved will be paid by the employer or insurance company out of any compensation benefits due.
Injured workers or dependents of deceased workers should not directly pay anything to the attorney or licensed representative
representing them in a compensation case.
7. If you need help returning to work, or with family or financial problems because of your injury, contact the Workers' Compensation
Board office nearest you and ask for a rehabilitation counselor or social worker.
This form should be filed by sending directly to the address listed below:
New York State Workers' Compensation Board
Centralized Mailing
PO Box 5205
Binghamton, NY 13902-5205
Customer Service Toll-Free Number: 877-632-4996
C-3.0 (1-11)
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New York Workers' Compensation Claimant Information Packet

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Completed 19 February 2020

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