A) an Employee Claim form; - web plattsburgh 2025

1. Click ‘Get Form’ to open the Employee Claim form in the editor.
2. Begin with Section A, 'Your Information.' Fill in your full name, date of birth, mailing address, Social Security number, phone number, gender, and whether you need a translator for Board hearings.
3. Move to Section B, 'Your Employer(s).' Enter the name of your employer at the time of injury, their contact number, work address, date hired, supervisor's name, and any other employers you had during that time.
4. In Section C, 'Your Job on the Date of Injury or Illness,' provide your job title, typical activities performed at work, type of employment (full-time/part-time), gross pay per period, and payment frequency.
5. Proceed to Section D for 'Your Injury or Illness.' Document the date and time of injury/illness occurrence, location details, actions leading to the injury/illness, and nature of your injury. Be thorough in describing all relevant details.
6. Complete Section E regarding your return to work status. Indicate if you stopped working due to the injury and if you've returned to work since then.
7. Finally, fill out Section F about medical treatment received for your injury. Include dates of treatment and healthcare provider information as necessary.
8. Review all sections for accuracy before signing at the end of the form. Ensure all required fields are completed.

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