Form C-11 - Employer'S Report Of Injured Employee'S Change In Employment Status Resulting From Injury 2009 Page 2

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INSTRUCTIONS TO THE EMPLOYERS
Reports should be sent directly to the district offices at these addresses:
ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin,
Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington.
BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome,
Chenango,
Chemung,
Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins.
BUFFALO 14202 - 369 Franklin Street. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara.
ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario,
Orleans, Seneca, Steuben, Wayne, Wyoming, Yates.
SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida,
Onondaga, Oswego, St. Lawrence.
DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY
13902-5205.
NYC (800) 877-1373
Hemp. (866) 805-3630
Haup. (866) 681-5354
Peek. (866) 746-0552 For all accidents in
following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester.
Statewide Fax Line: 877-533-0337
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
C-11 (8-09) Reverse

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