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New York Form Center


Welcome to the most extensive library of workers' compensation forms available anywhere. Almost 3,000 forms are available for your immediate download and use. Our forms, all of which have been custom programmed by WorkersCompensation.com for Type & Save functionality, are available for individual purchase below.

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(a9) Agreement to Pay Medical Costs in the Event of Failure to Prosecute or if Compensation Claim is Disallowed - 1/07
(adr1) Alternative Dispute Resolution Program Final Disposition or Settlement of Claim - 8/09; Note: Print form on WHITE paper, not green.
(adr1 1) Alternative Dispute Resolution Program Modification of Previous Report - 8/09
(adr2) Alternative Dispute Resolution Program Report of Injury - 8/09; Note: Print form on WHITE paper, not green.
(aff1) Affidavit for Death Benefits - 8/09
(aff2) Affidavit for Death Benefits (Dependent Brothers / Sisters / Grandchildren) - 8/09
(aff3) Affidavit for Death Benefits (Dependent Parents/Grandparents) - 8/09
(bp-1) Affidavit of Exemption to Show Specific Proof of Workers Compensation Insurance - 12/08
(c2) Employer's Report of Accident - 8/09
(c3) Employee's Claim for Compensation - 8/09
(InjuredOnTheJob) Injured On The Job, An Employee\'s Guide to Workers\' Compensation in New York State - 9/08
(c3 1) Notice to Consent to Utilize An Employer or Carrier Recommended Network or Health Care - 3/04
(c3 3) Limited Release of Health Information - 11/08
(c3S) Reclamaciòn De Compensaciòn Para Empleados - 8/09
(c4) Attending Doctor's Report - 8/09
(c4 1) Continuation to Carrier/Employer Billing Section of Form C-4 - 9/08
(c4 2) Doctor's Progress Report - 8/09
(c4 3) Doctor's Report of MMI/Permanent Impairment - 8/09
(C-4AMR) Ancillary Medical Report - 8/09
(c4AUTH) Attending Doctor's Request For Authorization And Carrier's Response - 8/09
(c5) Attending Ophthalmologist's Report - 8/09
(c7) Notice That Right to Compensation is Controverted - 8/09
(c8 1) Notice of Treatment Issue/Disputed Bill - 8/09
(c8 4) Notice To Health Care Provider And Injured Worker Of A Carrier's Refusal To Pay All (Or A Portion Of) A Medical Bill Due To Valuation Objection(S)- 9/08
(c8 86) Notice That Payment of Compensation Has Been Stopped or Modified - 8/09
(c11) Employer's Report of Injured Employee's Change in Status or Return to Work - 8/09
(c21) Application for Advance on Periodic Payments of Compensation - 8/09
(c22) Application for Approval of Non-Schedule Adjustment print form on 14" paper - 8/09
(c25) Application for Reopening of Claim, More Than Seven Years After Accident - 8/09
(c27) Medical Proof of Change in Condition in Support of Application for Reopening - 8/09
(c32) Settlement Agreement, Section 32 - 11/09
(c32 1) Settlement Agreement: Claimant Release - 8/09
(c62) Claim for Compensation in Death Case - 8/09
(c64) Proof of Death by Physician Last in Attendance on Deceased - 8/09
(c65) Proof of Burial and Funeral Expenses by Undertaker - 8/09
(c72 1) Record of Percentage Hearing Loss - 2/04
(c105 31) Notice of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL - 1/04
(c105 32) Notice of Election of a Partnership or Sole-Proprietorship to Bring Partners or Self-Employed Persons Under the Coverage of the WCL - 4/04
(c105 41) Revocation of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL - 1/04
(c105 51) Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage - 1/04
(c105 52) Notice of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage - 1/04
(c105 53) Revocation of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage - 1/04
(c105 54) Notice of Election to Bring Sheltered Workshop Participants Under Coverage of WCL - 3/99
(c105 55) Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage - 1/04
(c121) Claim for Compensation and Notice of Commencement of Third Party Action - 8/09
(c240) Employer's Statement of Wage Earnings Preceding Date of Accident - 8/09
(c250) Notice of Claim for Reimbursement Out of Special Disability Fund Under Section 15-8 - 3/07
(c251) Carrier's Request for Reimbursement of Compensation Payments Under Section 15-8 print on Yellow paper - 11/01
(c251 1) Carrier's Request for Reimbursement of Medical Expenses Under Section 15-8 print on Pink paper - 11/01
(c251 2) Carrier's Request for Reimbursement of Compensation Payments Under Section 14(6) Concurrent Employment print on Blue paper - 11/01
(c251 3) Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) and Section 15(8) - 8/09
(c257) Claimant's Record of Medical and Travel Expenses - 10/07
(c300 34) Statement of Unresolved Issues (Special Part for Expedited Hearings) - 10/97
(c300 5) Stipulation - 7/97
(c430s) Statement of Rights (WCL) - 8/09
(c669) Notice to Chair of Carrier's Action on Claim for Benefits - 8/09
(cb11) Conciliation Process (Rights and Responsibilities - 11/06
(cb11s) Conciliation Process (Rights and Responsibilities (Spanish) - 1/07
(db102) Information for Employer Regarding Disability Benefits Law - 8/09
(db118) Employer's Statement for the Purpose of Terminating Status as a Covered Employer Last update: 8/09
(db125) Employer Identification Card - 2/05
(db130) Employee's Statement of Exempt Status - 5/02
(db135) Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (No Employee Contribution) - 8/03
(db136) Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (Employee Contribution) - 8/03
(db159 1) Notice of Termination of Employer's Participation in Self-Insured Association, Union or Trustees Plan - 2/03
(db212 3) Notice of Election of a Corporation Which is Required to Have Disability Benefits Coverage for its Employees to Exclude the Sole Shareholder Officer or One of the Two or Both Shareholder Officers of the Corporation from Such Coverage - 1/04
(db212 5) Notice of Election of Voluntarily Exclude Spouse from Coverage - 11/06
(db271s) Statement of Rights (DBL) - 8/09
(db300) Notice of Proof of Claim for Disability Benefits of Unemployed Claimant - 2/04
(db310 3) Form Letter Requesting Medical Information - 10/07
(db450) Notice and Proof of Claim for Disability Benefits - 2/04
(DB-450 Spanish) Guía Para Llenar El Formulario Db-450, Notificación Y Constancia De La Solicitud De Los Beneficios Por Incapacidad - 3/07
(db451) Notice of Total or Partial Rejection of Claim for Disability Benefits - 3/99
(db455) Notice of Disability Benefits Payment - 3/99
(db470) Preliminary/Final Claim for Reimbursement of Benefits Paid Under DBL - 12/05
(db791) Tables of Permanent Contributions - 2/00
(db802) Employer's Application to Have Association, Union or Trustee Plan Accepted as Employer's Plan - 4/04
(db820 1) Certificate/Cancellation of Insurance - 10/08
(db840) Carrier's Designation of Authorized Representatives - 2/00
(db850) Application for Acceptance of Insurance Form - 3/02
(dc120) Discharge or Discrimination Complaint - 11/06
(DD-1) Direct deposit of benefit authorization form - 2/06
(DD-2) Biannual Recertification To Entitlement To Benefits - 9/05
(e-biz-1CL) Request for Access to Submit Claim Forms on the Web
(ec32 1) Claimant's Release Form - Section 32 Waiver Agreement (obsolete) - Replaced by Form C-32.1
(electronicattach) Attachment to Form_____ (may accompany any Board form.) - 5/01
(fce-4) Practitioner's Report of Functional Capacity Evaluation - 8/09
(himp 1) Health Insurer's Request for Reimbursement - 8/09
(HIPAA-1) Claimant's Authorization to Disclose Health Information (Pursuant to HIPAA) - 12/03
(hp1) Health Provider's Request for Decision on Unpaid Medical Bill(s) - 4/05
(hp4) Notice to Chair: Health - Provider's and Insurer's Withdrawal of Request for Arbitration - 4/05
(HPJ1) Provider's Request For Judgment Of Award - 7/08
(IG1) Fraud Compalint - 5/08
(ime3) Practitioner's Report of Request for Information/Response to Request Regarding Independent Medical Examination - 8/09
(ime4) Practitioner's Report of Independent Medical Examination - 8/09
(ime5) Claimant's Notice of Independent Medical Examination - 8/09
(ime7) Statement of Registration (Sec. 13n -WCL) - 4/05
(md-1) Attending Doctor's Request for Medical Authorization Determination - 8/09
(md-3) Carrier/Self-Insured Employer's Objection to Order of the Chair Authorizing Special Services - 8/09
(mr-ime-1) Health Provider's Application for Authorization Under the Workers' Compensation Law - 4/05
(oc110a) Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) - 8/09
(oc110as) Spanish version of OC-110a - 8/09
(oc400) Notice of Retainer and Substitution - 8/09
(oc400 1) Attorney/ Representative's Application for Fee - 8/09
(oc400 5) Attorney/Representative\'s Certification Of Form C-3 Or C-7 - 8/09
(oc406) Notice of Retainer and Appearance on Behalf of Employer - 5/08
(oc923) Letter to new Employer Re WC and DB Coverage - 8/09
(otpt4) Occupational/ Physical Therapist's Report - 8/09
(ph16 2) Pre-Hearing Conference Statement - 8/09
(ps4) Psychologist's Report - 8/09
(r) Carrier's Report on Rehabilitation - 8/05
(rb89) Cover Sheet - Application for Board Review - 8/09
(rb89 1) Cover Sheet - Rebuttal of Application for Board Review - 8/09
(rb89 2) Cover Sheet - Application For Full Board Review - 8/09
(rb89 3) Cover Sheet - Rebuttal Of Application For Full Board Review - 8/09
(rfa-1) Claimant's Request for Further Action - 8/09
(rfa-2) Carrier's/Employer's Request for Further Action - 8/09
(si-4) Self-Insurer’s Statement Of Outstanding Death Claims - 9/09
(si-4 1.pd) Self-Insurer’s Statement Of Outstanding Disability Claims - 9/09
(si-4 11) Instructions for Self-Insurer’s Statement Of Outstanding Death Claims and Instructions for Self-Insurer’s Statement Of Outstanding Disability Claims - 9/09
(si-6) Self-Insurer’s Report Of Payroll For All Operations - 9/09
(si-10 1) Report Of Cumulative Compensation Payments - 9/09
(si-10 1m) Report Of Cumulative Medical Payments - 9/09
(vaw1) Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death - 8/97
(vaw2) Political Subdivision's Report of Injury to Volunteer Ambulance Worker - 8/09
(vaw3) Volunteer Ambulance Worker's Claim for Benefits - 8/09
(vaw62) Claim for Volunteer Ambulance Workers' Benefits in a Death Case - 8/09
(vaw501) Volunteer Ambulance Workers Benefit Rates – Death Benefits - 1/06
(vf-vaw-10) Carriers request for benefit increase reimbursement under section 51 volunteer firefighters and volunteer ambulance workers benefit laws - 10/06
(vf-vaw-11) Volunteers Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV - 8/09
(vf1) Notice to Political Subdivision of Volunteer Firefighter's Injury or Death - 8/97
(vf2) Political Subdivision's Report of Injury to Volunteer Firefighter - 8/09
(vf3) Volunteer Firefighter's Claim for Benefits - 8/09
(vf62) Claim for Volunteer Firefighter Benefits in a Death Case - 8/09
(vf501) Volunteer Firefighters Benefit Rates – Death Benefits - 10/06
(wcdb-100) Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required - 9/07
(wcdb-101) Affidavit That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State Does Not Require Specific New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage - 7/04
(wtc-aff1) Affidavit for Death Benefits (September 11, 2001) - 8/06
(wtc-aff-dp) Domestic Partner's Affidavit for Death Benefits (September 11, 2001) - 8/06
(wtcvol-3) World Trade Center Volunteer's Claim for Compensation - 2/04
(wtc-12) Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations - 8/09
Cover Sheet: List of Itemized Medical Bills for Temporary Payment by the World Trade Center Volunteer Fund in Controverted World Trade Center Case - 7/07
Please note: Forms C-105, C-105.1, C-105.2, DB-120 and DB-120.1 are not available online. Contact your insurance carrier for these forms.