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OC-400 Reverse (12-21) It is unlawful to disclose individually identifiable information from Workers' Compensation Board records to any person who is not otherwise lawfully authorized to obtain these records.
C-107. Employer's Request for Reimbursement (NY State Insurance Fund) This is a New York State Insurance Fund form. If you are an employer insured by the NY State Insurance Fund, contact your local State Insurance Fund office for this form, or call toll-free (888) 875-5790.
APPLICATION FOR INCREASE IN AREA.
Filing A Workers' Compensation Claim The C-4 form is titled \u201cEmployee's Claim for Compensation/Report of Initial Treatment\u201d. The physician fills out their part of the form, and sends a copy to your employer and the insurer. Be sure to get a copy for your records.
Form C-3 Employer's Report Of Industrial Injury or Occupational Disease. As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of an accident. Fatalities must be reported within 24 hours.
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Filing A Workers' Compensation Claim The C-4 form is titled \u201cEmployee's Claim for Compensation/Report of Initial Treatment\u201d. The physician fills out their part of the form, and sends a copy to your employer and the insurer. Be sure to get a copy for your records.
For each percent of impairment, you will receive 0.6% of your average monthly wage at the time of your injury. For example, suppose you have 10% impairment, and your average monthly wage is $2,400. Your permanent partial disability award would be calculated as follows: (. 006) x $2,400 x 10 = $144 per month.
The RFA-2 is a New York State Workers' Compensation Board form. Specifically, it is a \u201cRequest For Further Action\u201d by the carrier or employer and can be found here. This form would be filed by the carrier or employer when a need for a hearing arises.
OC-400 Reverse (12-21) It is unlawful to disclose individually identifiable information from Workers' Compensation Board records to any person who is not otherwise lawfully authorized to obtain these records.
The C-3 Employee Claim form allows workers to make a claim for compensation benefits with the New York Workers' Compensation Board. It gathers your personal information, your work position in the company, the type of injury or illness you received while on the job, and whether you obtained medical treatment.

form c 3