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New york fillable c240 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the W.C.B. Case Number and Carrier's Case Number at the top of the form.
- Fill in the Date of Accident and Employee's Social Security Number, followed by their Address and Name.
- Indicate the type of employment (hourly, daily, weekly, or monthly) and provide the wage details for the injured employee.
- Answer whether the injured employee was in military service during the preceding 52-week period. If 'Yes', include the date of discharge.
- Complete the schedule of gross wage earnings for each week leading up to the accident, ensuring to check 'X' next to the appropriate employee name.
- If applicable, indicate any additional allowances such as free rent or bonuses and provide their weekly value.
- Certify that all information is true and correct by signing and dating at the bottom of the form.
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Related links
Aug 31, 2012 New International Student Orientations for FY 08-09. 3.03.03 C240 Firewalls Access Control Lists. $5.00. $0.00. CST C244 ComputerRead more
Completing Employers Statement of Wage Earnings (Form C-240) Enter the date the injured worker was injured or noticed they were ill. FOR COMPLETING INJURED