Fillable New York form C2F - Employer's First Report of Work-Related Injury/Illness

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New York form C2F - Employer's First Report of Work-Related Injury/Illness

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The New York form C2F - Employer's First Report of Work-Related Injury/Illness form is 3 pages long and contains:

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Page of
www.wcb.ny.gov
State of New York - Workers' Compensation Board
Employer's First Report of
Work-Related Injury/Illness
C-2F
A work-related injury or illness must be reported within 10 days (Per Section 110) of the injury/illness or be subject to a penalty.
Employers are not required to submit form C-2F to the Workers' Compensation Board if the employer's insurer will be submitting
the accident information electronically to the Board on the employer's behalf. If you need assistance completing this form, please
contact your insurer for guidance on the best method of reporting work-related accident information. If you submit this form to
the Board, please send it to P.O. Box 5205, Binghamton, NY 13902 and provide a copy to your insurer.
Employee Name
WCB Case Number (JCN) Date of Injury
Claim Administrator Claim Number
INSURER / CLAIM ADMINISTRATOR INFORMATION
Insurer Name Insurer ID
Name
Info/Attn
Address
City State
Postal Code Country
Claim Admin ID
EMPLOYEE INFORMATION
First Name
Middle Name/Initial
Last Name Suffix
Mailing Address
City
State
Postal Code
Country
Phone Number
Date of Birth
Date of Hire
Employee SSN
Occupation Description
Gender
Male
Female
Unknown
Page of
www.wcb.ny.gov
CLAIM INFORMATION
Time of Injury Date Employer Had Knowledge of the Injury
Date Employer Had Knowledge of Date of Disability
Employment Status
Estimated Weekly Wage Number of Days Worked Per Week
Work Week Type
Standard Work Week
Fixed Work Week
Varied Work Week
Work Days Scheduled
Sun Mon Tues Wed Thurs Fri Sat
EMPLOYEE INJURY
Date of Death
Number of Dependents
Nature of Injury (i.e. Laceration, Burns, Fracture, Strain, etc)
Part of Body (i.e. left arm, right foot, head, multiple, etc)
Cause of Injury (i.e. Motor Vehicle, Machine, Strain or Injury by lifting, etc)
Full Wages Paid for Date of Injury
Yes
No
Employer Paid Salary in Lieu of Compensation
Yes
No
Initial Treatment
No Medical Treatment Minor On-Site Treatment By Employer Minor Clinic/Hospital Treatment
Hospitalization Greater Than 24 Hours
Emergency Evaluation
Future Major Medical/Lost Time Anticipated
Death Result of Injury
Yes
No
Unknown
Accident/Injury Description (see instructions)
WORK STATUS
Initial Return to Work Date
Initial Date Last Day Worked
Initial Date Disability Began
Return To Work Type
Actual
Released
Physical Restrictions
Yes
No
Return To Work Same Employer
Yes
No
ACCIDENT LOCATION AND WITNESSES
Organization Name
Street State
City
Postal Code
County Country
Location Narrative
Employer
Lessee
Other
Premises (see instructions)
Witnesses Business Phone Number
Page of
www.wcb.ny.gov
EMPLOYER INFORMATION
Name
Employer FEIN
UI Number
Manual Classification Code
Industry Code
Info/Attn
Mailing Address
City State
Postal Code Country
Physical Addr
City State
Postal Code Country
Contact Name
Contact Business Phone Number
INSURED INFORMATION
Insured Name Insured FEIN
Insured Location ID
Policy Number ID
Policy Effective Date
Policy Expiration Date
Insured Type
Insured
Self-Insured
Uninsured
An employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, 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.
Signature of Person Preparing Form
If prepared by the employer:
Date
Print Name
Title
Phone Number
The above information is true to the best of my knowledge and belief.
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New York form C2F - Employer's First Report of Work-Related InjuryIllness

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Completed 19 September 2019

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