Form C-2 - Employer'S Report Of Work-Related Injury/illness Page 3

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DATE OF INJURY/ILLNESS:______/______/______

EMPLOYEE'S NAME:

First

Last

G. EMPLOYEE'S WORK INFORMATION on the date of the injury or illness

1. Date the employee was hired: ______/______/______

2. What was the employee's job title?

3. What types of activities did the employee normally perform at work? (Attach job description if available.)____________________________

H. EMPLOYEE'S PAYROLL INFORMATION on the date of the injury or illness

1. Employee's gross pay in an average week was: $

2. Did the employee receive lodging or tips in addition to pay?

If yes, describe:

Yes

3. Employee's job was (check one):

Full Time

Part Time

Seasonal

Volunteer

Other:__________________

4. Which days of the week did the employee usually work?

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

Sun.

Yes

5. Was the employee paid for a full day on the day of the injury/illness?

6. Did you continue to pay the employee after the injury/illness (e.g., sick leave, vacation, disability, regular salary)?

Yes

I. ADDITIONAL INFORMATION

An employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who KNOWINGLY MAKES

A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a

claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE

GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

The above information is true to the best of my knowledge and belief.

If prepared by the employer:

Signature of Person Preparing Form:

Date: ______/______/______

Print Name:

Title:

Phone Number: (______)______________

If prepared by a Third Party on Behalf of the Employer:

Signature of Person Preparing Form:

Date: ______/______/______

Print Name:

Title:

Phone Number: (______)______________

Company Name and Address:

Name & Phone Number of Person Who Provided Information Necessary to Prepare This Form:

Reports should be filed by sending directly to the appropriate WCB district office (DO) at the address below with a copy sent to the insurance carrier:

Albany DO - 100 Broadway-Menands, Albany NY 12241 866-750-5157 (for accidents in the following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton,

Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington)

Binghamton DO - State Office Building, 44 Hawley Street, Binghamton NY13901 866-802-3604 (for accidents in the following counties: Broome, Chemung, Chenango, Cortland,

Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins)

Buffalo DO - 295 Main Street, Suite 400, Buffalo NY 14203 866-211-0645 (for accidents in the following counties: Cattaraugus, Chautauqua, Erie, Niagara)

Rochester DO - 130 Main Street West, Rochester NY 14614 866-211-0644 (for accidents in the following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans,

Seneca, Steuben, Wayne, Wyoming, Yates)

Syracuse DO - 935 James Street, Syracuse NY 13203 866-802-3730 (for accidents in the following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga,

Oswego,St. Lawrence)

Downstate Centralized Mailing - PO Box 5205, Binghamton NY, 13902-5205 for all DO's in NYC 800-877-1373; in Hempstead 866-805-3630; in Hauppauge 866-681-5354;

in Peekskill 866-746-0552 (for accidents in the following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester)

C-2.0 (1-11)

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Statewide Fax Line: 877-533-0337