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Instructions for Completing Employee Claim (Form C-3) Please complete this form and send it to the Workers' Compensation Board centralized mailing address listed at the end of these instructions.
State of New York - Workers' Compensation Board. THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL. Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Required items are indicated by an * Employee Info. Employer Info. Job Info. Injury or Illness Info. Return to Work.
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.
Please complete this form and send it to the Workers' Compensation Board centralized mailing address listed at the end of these instructions. If you need additional help completing this form, contact the Workers' Compensation Board at 1-877-632-4996. You may also fill this form out online at wcb.ny.gov.
State of New York - Workers' Compensation Board. Fill out this form to apply for workers' compensation benefits because of a work injury. C-3 RU ZRUN UHODWHG LOOQHVV 7\SH RU print neatly. This form may also be filled out on-line at www.wcb.ny.gov. WCB Case Number (if you know it): A. YOUR INFORMATION (Employee) 1. Name: First. MI. Last. 2.
Printing T:\\AAOSHARE\\FINLFORM\\C3.FRP. Employee Claim. State of New York - Workers' Compensation Board. Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type print neatly. This form may also be filled out on-line at www.wcb.ny.gov.
Determine the classification code applicable to all employees of the business, including clerical workers, salespersons, and executive officers (unless they are excluded from coverage). Do not include subcontractors and independent contractors. List each classification code on the application.
