Workers' Compensation Claims

In New York State, if you are injured on your job, you may be entitled to Workers' Compensation benefits.

Please fill out the required fields as thoroughly as possible and provide any additional information that may help us assist you in this matter.

* denotes a required field

Background Information

First Name: *

Last Name: *

Referred By:

Address: *

City: *

State: *

Zip: *

Date of Birth:

Age:

Email Address: *

Telephone Number: *

Cell Phone Number:

Work Phone Number:

Insurance Carrier:

Carrier Address:

Carrier Case #:

Employer:

Employer's Address:

WCB#:

Date of Accident:

Description of Accident

Where did the accident happen?

How did the accident happen?

Did anyone witness the accident? If Yes, list names:

Did the accident involve the use of a machine, tool or construction equipment? If yes, describe the machine, tool, etc:

Did the accident involve a motor vehicle?

Did you have more than one accident? If yes, list dates:

Notice to Employer

Did you tell your supervisor about the accident?

Did you tell them in writing? If yes, do you have a copy of what you gave your employer?

Did you fill out an accident report? If yes, do you have a copy of it?

Employees Claim for Compensation Form, (C-3)

Did you file an employee's claim for compensation form (C-3) with the Workers Compensation Board? If yes, when did you file the C-3 form?

Description of Injury

What part[s] of your body was [were] injured?

Describe your physical complaints resulting from your injury:

Did you have prior injuries to this [these] body part[s]? If yes, describe:

Were these prior injuries the result of a prior work related injury? If yes, provide the date of accident and WCB#:

Medical Treatment

Provide the name, date and address of the first place you received medical treatment for the injury:

Provide the name(s) and address(es) of your treating physicians:

Date of most recent Doctor Visit:

Which doctor did you see on that date?

Wages

What is your average wage per week?

What is your average wage per hour?

How many hours per week do you work?

How many days per week do you work?

Concurrent Employment

At the time of the accident did you work for any other employer(s)? If yes, name and address of other employer(s):

Lost Time From Work

Since your accident, have you continued to work in your usual capacity?

Are you working in a lighter duty position?

If you are not working, when was the last day of work?

Compensation Payments

If you are out of work, does your employer continue to pay your full wages to date?

If not, are you receiving payments from the compensation insurance carrier?

If yes, how much are you receiving per week?

Compensation Hearing

Have you had a workers compensation hearing?

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