NY Workers' Comp Claims
Personal and Commercial Claims
Certificate Request
Forms Descriptions
Form C-240- Employer's Statement of Wage Earnings (Preceding the Date of Accident)
This form should be completed any time the lost time exceeds the waiting period by seven calendar days. This will provide the Carrier with the necessary information in order to calculate an average weekly wage which will be the basis for Workers' Compensation benefits.
- Give gross weekly earnings for the 52-week period immediately preceding the date of the accident.
- If the injured worker has not worked at the same work for a year or a substantial part of the year (234 days for a 5 day a week worker and 270 days for a 6 day a week worker) give the weekly gross earnings of another employee of the same class who has worked for a year or a substantial part of the year immediately preceding the date of the accident.
Form C-11 - Notice of Return to Work Change in Employment Status
Form C-11 entitled "Employer's Report of Injured Employee's Change in Employment Status Resulting from Injury" must be completed as soon as the employment status of an injured worker changes from that reported on the C-2 or previously submitted C-11.
Change in employment status, if related to the injury, includes the following:
- Return to work
- Discontinuance of work
- Increase/decrease of regular hours of work
- Increase/decrease in wages
Form C-107 - Employer's Request for Reimbursement
This form is used principally as evidence of a claim for reimbursement by an employer for monies advanced to an injured worker on account of a compensation claim. Workers' Compensation Law indicates: "if the employer has made advance payment of compensation, or has made payments to an employee in like manner as wages during any period of disability, he shall be entitled to be reimbursed out of an unpaid installment or installments of compensation due, provided, his claim for reimbursement is filed before award of compensation is made, or, if the insured, by the insurance carrier at the direction of the board, unless he shall file a waiver of reimbursement with the chairman, in which event compensation will be paid to the claimant notwithstanding the advance payments.."
Payments will be reimbursed at the Workers' Compensation rate only.
It is recommended that, while payments are being advanced, the C-107 is completed monthly.
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