Forms

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)

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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)
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

IMPORTANT NOTICE: NEW VENDOR FOR MEDICAL BILL REVIEW & PHARMACY BENEFITS MANAGEMENT