Form C-2 - Employer'S Report Of Work-Related Injury/illness

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EMPLOYER'S REPORT OF WORK-RELATED INJURY/ILLNESS
C-2
State of New York - Workers' Compensation Board
If one of your employees has a work-related injury or illness, you must complete and file this form within 10 days of the
injury/illness or be subject to a penalty. For additional information on filing this form please refer to Workers'
Compensation Law Section 110 at the end of this form. Type or print neatly.
WCB Case Number (if you know it):
Date of Injury/illness: ________/________/________
Carrier Case Number (if you know it):
Date of this Report: ________/________/_________
A. EMPLOYER INFORMATION
1. Employer:
2. Employer FEIN:
3. Mailing Address:
4. Location Address (if different):
5. Phone Number: (______)______________________
6. Nature of Business or Industry Code:
7. OSHA Case Number (if known):
8. NY UI Employer Reg Number:
B. INSURANCE CARRIER / SELF-INSURED EMPLOYER
If individually self-insured, enter your Board W Number and skip to Section C.
1.Board W Number: W
2. Carrier/Group Name:
3. Policy Number:
Policy Period: From: ______/______/______ To: ______/______/______
5. Phone Number: (______)_____________
4. If Carrier Unknown, Insurance Agent Name:
C. EMPLOYEE'S PERSONAL INFORMATION
2. Date of Birth: ______/______/______
1. Name:
First
MI
Last
3. Mailing Address:
6. Gender:
Male
Female
4. Social Security Number:
5. Contact Phone Number:(______)_______________
D. EMPLOYEE'S INJURY OR ILLNESS
AM
PM
1. Time of day employee began work on date of injury:
2. Time of injury:
AM
PM
3. Has the employee given you notice of injury/illness?
Yes
No
Date notice provided: ______/______/______
orally
in writing
If yes, notice was given to: _________________________________
If available, attach a copy of the employee's written notice and medical notes, and the employer's incident report.
If yes, give date: ______/______/______
4. Have you given the employee a Claimant Information Packet?
Yes
No
5. Where did the injury/illness happen (e.g., 1 Main St., Pottersville, at the front door):
6. Was this location where the employee normally worked?
Yes
No
If no, why was the employee there?
7. Employee's supervisor: ____________________________________
8. Did supervisor see injury happen?
Yes
No
Unknown
Yes
No
Unknown
9. Did anyone else see the injury happen?
If yes, give name(s): ___________________________________
10. What was the employee doing when he/she was injured or became ill? (e.g., unloading a truck, stocking a shelf, typing annual report)
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE
C-2.0 (1-11)
Page 1 of 3
WITH DISABILITIES WITHOUT DISCRIMINATION

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