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C-107: Employer's Request for Reimbursement Promptly report advance payments of compensation to the injured worker on Form C-107 to be reimbursed before the Workers’ Compensation Board makes a compensation award.
Employers insured for workers' compensation through a private insurance carrier. Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The C-105.2 must be completed by the insurance carrier or its licensed insurance agent.
Common Workers' Compensation Board Forms. If the form you are looking for is not listed above, or in the list of Common Board Forms, please email the Board's Forms Department.
C-107: Employer's Request for Reimbursement - file for reimbursement for wages paid to an injured employee. C-240: Employer's Statement of Wage Earnings Preceding Date of Accident - failure to file within 10 days of request by the WCB may result in penalties. C-240 Instructions: Step-by-step instructions on completing form C-240. C-256.2
View, download and print fillable C-107 - Nysif - Employer's Request For Reimbursement in PDF format online. Browse 4 Nysif Forms And Templates collected for any of your needs.
Workers’ Compensation Insurance Notice of Compliance (Form C-105) If necessary, contact EMPLOYERS or your licensed New York insurance agent; Anti-Fraud Notice (English and Spanish) The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
INSTRUCTIONS. This form is used principally as evidence of a claim for reimbursement by an employer for monies advanced to a claimant on account of compensation due under the provisions of the Workers’ Compensation Law.
