Form C-11 - Employer'S Report Of Injured Employee'S Change In Employment Status Resulting From Injury 2009

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STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE
IN EMPLOYMENT STATUS RESULTING FROM INJURY
This report is to be filed directly with the Chair, Workers' Compensation Board at the address shown on reverse side as soon as the
employment status of an injured employee, as reported on Form C-2 or EC-2, or on a previous Form C-11 or EC-11, is changed.
Change in employment status includes return to work, discontinuance of work, increase or decrease of regular hours of work and
increase or reduction of wages. A copy should also be sent to your insurance carrier.
ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS
3. Carrier Code
4. Date of Injury
5. Claimant's Soc. Sec. No.
1. W.C.B. Case Number
2. Carrier Case Number
N a m e
Address to which notice should be sent (Give Number and Street, City, State, and Zip Code)
6. Injured
Apt.No.
Person
7. Employer
8. Carrier
9. Date of most recent Employer's Report filed:
C-2
EC-2_____________
C-11/EC-11_____________
(check "x" & give date filed)
/
10. Date of first full day employee lost from work: ___________________________
11. Nature of Injury:_________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
12. Date employee returned to work: __________________________________
13. (a) Change of employment status resulting from above injury:
Employment
Hours per
Days per
Earnings
Occupation
Status
Day
Week
Prior To
Injury
Changed To
(b) Date of this change in employment status:____________________ (c) Remarks:____________________________________
______________________________________________________________________________________________________
14. Loss of time resulting from above injury since first return to work:
From (Mo., Day, Year)
TO (Mo., Day, Year)
Reason
15. Is injured person still under physician's care?______ If yes, give name of physician:______________________________________
16. Has injured person died?_______ If yes, give date of death:_____________________________
Name and address of nearest known relative:_____________________________________________________________________
Date of this Report_________________
No.______________________Firm Name___________________________________
Tel.
Prepared By:_________________________________________ Official Title____________________________________________
C-11
C-11
C-11
C-11
C-11
(8-09)

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