Form C-3 - Employee Claim - State Of New York - Workers' Compensation Board
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2C-3
Employee Claim
State of New York - Workers' Compensation Board
Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type or
print neatly. This form may also be filled out on-line at
WCB Case Number (if you know it):
A. YOUR INFORMATION (Employee)
2. Date of Birth: ______/______/______
1. Name:
First
MI
Last
3. Mailing address:
Number and Street/PO Box
City
State
Zip Code
-
-
5. Phone Number: (_____)_______________
4. Social Security Number:
6. Gender:
Female
Male
7. Will you need a translator if you have to attend a Board hearing?
Yes
No If yes, for what language?
B. YOUR EMPLOYER(S)
2. Phone Number: (_____)_______________
1. Employer when injured:
3. Your work address:
Number and Street
City
State
Zip Code
4. Date you were hired: _____/_____/_____
5. Your supervisor's name:
6. List names/addresses of any other employer(s) at the time of your injury/illness:
7. Did you lose time from work at the other employment(s) as a result of your injury/illness?
Yes
No
C. YOUR JOB on the date of the injury or illness
1. What was your job title or description?
2. What types of activities did you normally perform at work?_________________________________________________________________
3. Was your job? (check one)
Full Time
Part Time
Seasonal
Volunteer
Other:____________________
4. What was your gross pay (before taxes) per pay period?
5. How often were you paid?
6. Did you receive lodging or tips in addition to your pay?
If yes, describe:
Yes
No
D. YOUR INJURY OR ILLNESS
1. Date of injury or date of onset of illness: ______/______/______
2. Time of injury:
AM
PM
3. Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)
4. Was this your usual work location?
Yes
No
If no, why were you at this location?
5. What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report) _______________________________
6. How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)
7. Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):______________________
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE
C-3.0 (1-11) Page 1 of 2
WITH DISABILITIES WITHOUT DISCRIMINATION
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