Home
Forms Library
Revised C-4 Form Employee's Claim for Compensation

Revised C-4 Form Employee's Claim for Compensation 2025

Revised C-4 Form Employee's Claim for Compensation Preview on Page 1

See details

4.1 out of 5

29 votes

The document is a Form C-4, used for employees to file a claim for compensation related to injuries or occupational diseases. It requires detailed personal information from the employee, including their name, address, occupation, and specifics about the injury or disease. The form also includes sections for medical treatment details, witness information, and certifications regarding the accuracy of the provided information. It emphasizes the need for timely submission within three working days of treatment.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Revised C-4 Form Employee's Claim for Compensation with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the Revised C-4 Form in the editor.
Begin by filling in your personal information, including your first name, middle initial, last name, birthdate, and home address. Ensure all details are accurate for processing.
Next, provide your claim number (if applicable), social security number, and contact information. This section is crucial for tracking your claim.
In the 'Employer’s Name' section, enter the name of your employer along with their contact details. Include the date and location of the injury if relevant.
Detail the nature of your injury or occupational disease in the designated fields. Be specific about how it occurred and any witnesses present.
Finally, review all entered information for accuracy before signing electronically. Use our platform’s features to ensure everything is complete and correct.

Start using our platform today to fill out your Revised C-4 Form effortlessly and for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is Workers Compensation CT Form 43?

The Form 43 is to be completed by the respondent (employer/workers compensation insurance carrier) to notify the Administrative Law Judge, the claimant (employee/decedent), and all parties to the claim of its intention to deny the compensability of all or part of the claimants claim to workers compensation benefits.

How to file a workers comp claim in Nevada?

Complete the Notice of Injury or Occupational Disease, Form C-1. You must fill out this form and turn it in to your employer within one week of your injury. If your work-related injury requires medical treatment, you will need to fill out Form C-4, Employees Compensation Report of Initial Treatment.

What is a C43 form?

C-4.3. Use this form: 1. When rendering an opinion on MMI and/or permanent partial impairment; or 2. In response to a request by the Workers Compensation Board to render a decision on MMI and/or permanent partial impairment.

How long do you have to file a workers comp claim in NY?

New York law states that workers have up to two years to file a claim if they are suffering from a work-related illness or injury. For occupational hearing loss, workers have up to three months to report the injury and 90 days to file a workers compensation claim.

What is the timely filing limit for workers comp in NY?

ing to the guidelines you have: Two years from the date of the workplace accident that resulted in your injury or. Two years from the time you knew or should have known the occupational disease stemmed from the nature of your job.

What are the limits on workers compensation in NY?

C. VOLUNTARY COMPENSATION INSURANCE Bodily Injury by Accident:$100,000-each accident Bodily Injury by Disease: $100,000-each employee Bodily Injury by Disease: $500,000-policy limit

How long do you have to report a workers comp claim in NY?

When to File. You must notify your employer within 30 days, but it is best to do so as soon as possible. If 30 days pass and you have not notified your employer, you may lose your rights to workers compensation benefits.

What is the waiting period for WC in NY?

Employees who are eligible for wage replacement benefits pursuant to the Workers Compensation Law receive no wage replacements for the first seven calendar days of disability (which is the Workers Compensation Law initial waiting period), unless the disability extends beyond 14 calendar days.

Revised C-4 Form Employee's Claim for Compensation 2025

Here's how it works

How to use or fill out Revised C-4 Form Employee's Claim for Compensation with our platform

Complete this form in 5 minutes or less

Got questions?

What is Workers Compensation CT Form 43?

How to file a workers comp claim in Nevada?

What is a C43 form?

How long do you have to file a workers comp claim in NY?

What is the timely filing limit for workers comp in NY?

People also ask

What are the limits on workers compensation in NY?

How long do you have to report a workers comp claim in NY?

What is the waiting period for WC in NY?

Related links

Try more PDF tools

Revised C-4 Form Employee's Claim for Compensation 2025

Here's how it works

How to use or fill out Revised C-4 Form Employee's Claim for Compensation with our platform

Complete this form in 5 minutes or less

Got questions?

What is Workers Compensation CT Form 43?

How to file a workers comp claim in Nevada?

What is a C43 form?

How long do you have to file a workers comp claim in NY?

What is the timely filing limit for workers comp in NY?

Related Searches

People also ask

What are the limits on workers compensation in NY?

How long do you have to report a workers comp claim in NY?

What is the waiting period for WC in NY?

Related links

Try more PDF tools