CE-200 (exemption form) - Workers' Compensation Board - NY 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Claim Information section. Enter the Date of Injury/Illness and WCB Case #, ensuring all communication includes these numbers.
3. In the Injured Worker Information section, provide your Last Name, First Name, Mailing Address, City, State, Zip Code, Daytime Phone #, Email Address, Social Security #, Date of Birth, and Gender.
4. Complete the Employer Information section with your Employer's Name and Mailing Address. Specify whether the Tax ID # is an SSN or EIN.
5. In the Reason for this Request section, check all applicable boxes and attach any required documents as indicated. Be sure to include additional information if necessary.
6. Finally, sign and date the form at the bottom before submitting it via mail or email to the Workers' Compensation Board.

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