FastFax Notice of Injury
To assist in expediting the initial reporting, we have introduced the FDM FastFax Notice of Injury. The district can fax (845-352-2022), or email ([email protected]) us information to get the claim started, then follow up with the completion of the C-2F form. THE FAST FAX IS NOT IN LIEU OF THE C-2F FORM.
Common Workers' Compensation Board Forms
(downloadable/fillable PDFs unless otherwise indicated)
| C-2F | English | Employer's Report of Work-Related Injury/Illness | Employer | FDM | Within 10 days after occurrence of injury/illness |
| C-2F | Spanish | Employer's Report of Work-Related Injury/Illness | Employer | FDM | Within 10 days after occurrence of injury/illness |
| C-3 | English | Employee Claim | Employee | FDM, in the event of on-the-job injury or illness | Within 2 years of accident, or within 2 years after employee knew or should have known that injury or illness was related to employment |
| C-3 | Spanish | Employee Claim | Employee | FDM, in the event of on-the-job injury or illness | Within 2 years of accident, or within 2 years after employee knew or should have known that injury or illness was related to employment |
|
C-11 NOTE: Only current version accepted |
English | EnglishEmployer's Report of Injured Employee's Change in Employment Status Resulting From Injury | Employer | FDM | As soon as employment status of injured employee changes |
| C-62 | Claim for Compensation in Death Case | Claimant (The claimant is the surviving spouse, child or dependent of the deceased. See the reverse of the form for details on who may file a claim in a death case.) | FDM in the event of on-the-job death | Within two years of accidental death. | |
| C-64 | Proof of Death by Physician Last in Attendance on Deceased | Health Provider | FDM | Upon death of claimant, or when requested by WCB | |
| C-65 | Proof of Burial and Funeral Expenses by Undertaker | Undertaker | FDM | When requested by WCB | |
| C-240 | Employer's Statement of Wage Earnings Preceding Date of Accident | Employer | FDM | Within 10 days of request by WCB | |
| DD-1 Direct Deposit Authorization | English | Direct Deposit Authorization Sample Form | To begin, change or cancel the transmittal of workers' compensation benefit checks and/or proceeds from a settlement agreement pursuant to WCL § 32 directly to a financial institution. This is a sample form only. Claimant should fill out the form on their insurer or administrator's website and submit the form directly to them. | FDM | |
| DD-1 Direct Deposit Authorization | Spanish | Direct Deposit Authorization Sample Form | To begin, change or cancel the transmittal of workers' compensation benefit checks and/or proceeds from a settlement agreement pursuant to WCL § 32 directly to a financial institution. This is a sample form only. Claimant should fill out the form on their insurer or administrator's website and submit the form directly to them. | FDM | |
| VF-1 | English | Notice to Political Subdivision of Volunteer Firefighter's Injury or Death | Volunteer Firefighter | FDM & political subdivision liable for benefits [This is not a claim for benefits. See VF-3] | Within 90 days after date of injury or death (unless claim form VF-3 or VF-62 is filed within that period) |
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VF-3 NOTE: Only current version accepted |
English | Volunteer Firefighter's Claim for Benefits | Volunteer Firefighter | FDM & political subdivision liable for benefits [If filed within 90 days of injury, it is not necessary to file VF-1.] | Within 2 years after injury is incurred. |
| VF-62 | English | Claim for Volunteer Firefighter Benefits in a Death Case | Claimant (The claimant is the surviving spouse, child or dependent of the deceased.) | Workers' Compensation Board and designated officer (see detailed instructions on form) | Within two years after death (but see also Form VF-1) |
An employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
Questions?
If you have any questions regarding the preparation of claim forms, please contact:
Claim Department
1 Blue Hill Plaza
PO Box 1609
Pearl River, NY 10965
Phone: 888-314-3004 | Fax: 845-352-2022