New York Required Postings
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/Occupational Disease 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 disease 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 one or more scheduled work days.
- Employer’s Statement of Wage Earnings Preceding Date of Accident. Promptly report accurate wage and attendance information about the injured worker to by submitting form C-240 to establish the validity of a claim and the compensation rate, if awarded.
- Employer’s Report of Injured Employee’s Change in Status. Report any change in a claimant’s work status as soon as it occurs by submitting Form C-11, including return to work, discontinuance of work, decrease in regular working hours or reduction of wages.
- Employer’s Request for Reimbursement. Promptly report advance payments of compensation to the injured worker on Form C-107 to be reimbursed before the Workers’ Compensation Board makes a compensation award.
- 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 also keep a copy on file for your records.
- Direct Deposit Authorization Form (DD-1). This form is optional and should be completed by the employee if they choose to receive their indemnity benefits or death benefits in the form of direct deposit.
- Diagnostic Tests & Exams Notice. To ensure prompt medical treatment, this form is required when an injured employee is in need of diagnostic testing.
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.