New York State Workers’ Compensation Forms
Please select a workers’ compensation form below:
- Insurance Certificate Request
- Loss Run Request
- C-105 Posting Notice Request
- First Aid Report
- VDF – 1 Form
New Claim Forms Packet
The Packet consists of required New York State Workers’ Compensation forms to be filled out by the injured employee.
- New Claim Forms Packet with Optum PBM
-
Individual Forms
- Dear Injured Worker Letter
- Workers’ Compensation Board Intro Letter
- Receipt for Employee Information Packet
- C-3 Form (“Employee Claim”).
- Instructions for Completing Form C-3 (“Employee Claim”)
- C-3.3 Form (“Limited Release of Health Information”)
- Statement of Rights.
- HIPAA Release
- Direct Deposit
- PT & Diagnostic Information Cards
- DT-1 Notice
- First Fill information Optum
New C-2F Form Document
(To be completed by employer)
The new C2F form has replaced the C2. This form can be completed and printed via the link below, or also completed electronically through the “Clients Only” section of this website. If you would like to login to complete this form electronically, please contact info@ncacomp.com for your username and password instructions.
C2F Form
Instructions for Completeing C2F Form
Other Important Claims Forms for Employers
- C-240, Employer’s Statement of Wage Earnings Preceding Date of Accident
- C-11, Employer’s Report of Injured Employee’s Change in Status or Return to Work
- Employer Reimbursement Request
- Claimant Vocational Questionnaire
- Physical Capabilities Form
Instructions for Completing Field-Fillable Forms
The field-fillable forms above can be completed in one of two ways:
- Fill out the form from your computer, and then print it out, and sign where indicated; or
- Print out the form and then fill it out by hand and sign.
- Forms can then be delivered by fax, mail, or in person to NCAComp or to the appropriate location.