Ny c11 2026

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The document is an Employer's Report form for notifying the New York State Workers' Compensation Board about changes in an injured employee's employment status due to their injury. It requires details such as the nature of the injury, changes in work hours, wages, and whether the employee is still under physician's care. The report must be filed promptly with the Board and a copy sent to the insurance carrier.

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Click ‘Get Form’ to open the ny c11 in the editor.
Begin by entering the W.C.B. Case Number, Carrier Case Number, and Carrier Code at the top of the form.
Fill in the injured person's name, Social Security Number, and date of injury. Ensure that you provide a complete address for notice delivery.
Indicate whether this report is a First Report of Injury by checking the appropriate box and providing the date filed.
Document the nature of the injury in detail, followed by the date when the employee returned to work.
In section 13(a), outline any changes in employment status, including hours per day, days per week, and earnings before and after injury.
Complete sections regarding loss of time from work and physician's care status as applicable.
Finally, review all entries for accuracy before submitting your report directly through our platform.

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Versions	Form popularity	Fillable & printable
2017	4.9 Satisfied (43 Votes)
2011	4.3 Satisfied (184 Votes)

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