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State of New York - Workers' Compensation Board. C-3. `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. WCB Case Number (if you know it): A. YOUR INFORMATION (Employee) 1. Name: 2.
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
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/
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/Apartment No. City State Zip Code 7.
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 ...
Complete NY WCB C-3 2019-2024 online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. Save or instantly send your ready documents.
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)
