New York Workers’ Comp Forms & Resources
New York Required Postings and Forms
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunchroom or time clock. If you have multiple locations be sure to print and post the notices at each location;
- Workers’ Compensation Insurance Notice of Compliance (Form C-105)
- If necessary, contact EMPLOYERS or your licensed New York insurance agent
- Anti-Fraud Notice (English and Spanish)
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- Employer’s Report of Work-Related Injury/Illness Form C-2F (First Report of Injury) 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 a work-related injury. Fatalities must be reported within 24 hours. Please use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Employer’s Statement of Rights - Disability Benefits Law. If you are unable to work because of a non-occupational illness or injury, you may be entitled to disability benefits.
- Employer’s Statement of Wage Earnings Form C-240. This form enables us to calculate the correct compensation that may be owed to your injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than three scheduled work days.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should keep a copy on file for your records.
The adjusting of the claims in this state are handled by Broadspire. Once a claim is reported to EMPLOYERS, the report will be sent to Broadspire for assignment.
More New York Workers’ Comp Resources
- Off-Site Transitional Duty Program - Helping Your Injured Employees Get Back to Work
A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.