Form C-2 - Employer'S Report Of Work-Related Accident/occupational Disease - 2006

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STATE OF NEW YORK
- WORKERS' COMPENSATION BOARD
EMPLOYER'S REPORT OF WORK-RELATED ACCIDENT/OCCUPATIONAL DISEASE
Send this notice directly to the Chair, Workers' Compensation Board at the address shown on the reverse side within ten (10) days after an
accident occurs. ANSWER ALL QUESTIONS FULLY. A copy should also be provided to or retained by your workers' compensation
insurance carrier.
Any employer who fails to timely file Form C-2, as required by Section 110 of the Workers' Compensation Law, is subject to a fine of not more than
$1,000. In addition, the Board or Chair may impose a penalty of up to $2,500.
Ļ
TYPEWRITER PREPARATION IS STRONGLY RECOMMENDED - INCLUDE ZIP CODE IN ALL ADDRESSES-EMPLOYEE'S S.S.NO. MUST BE ENTERED BELOW
WCB CASE NO.(If Known)
CARRIER CASE NO.
CARRIER CODE NO.
DATE OF ACCIDENT
EMPLOYEE'S S.S. NO.
WC POLICY NO.
y
m
m
d
d
y
W
1.(a) EMPLOYER'S NAME
(b) EMPLOYER'S MAILING ADDRESS
(c) OSHA CASE/FILE NO.
(f) NY UI EMPLOYER REG. NO.
(g) FEIN - if UI Emp. Reg. No. Unknown
(d) LOCATION (If Different From Mailing Address)
(e) NATURE OF BUSINESS (Principal Products, Services, etc.)
-
-
2.(a) INSURANCE CARRIER
(b) CARRIER'S ADDRESS
3.(a) INJURED EMPLOYEE (First, M.I., Last)
(b) ADDRESS (Includes No. & Street, City, State, Zip & Apt. No.)
4. (a) ADDRESS WHERE ACCIDENT OCCURRED
(b) COUNTY
(c) WAS ACCIDENT ON EMPLOYER'S
PREMISES?
A
Yes
No
C
C
m
m
d
d
y
y
5. HOUR EMP. BEGAN WORK
6. TIME OF ACCIDENT
7. DEPT. WHERE REGULARLY EMPLOYED
8
. (a) DATE STOPPED
(b) WAS EMPLOYEE PAID IN FULL
I
h
h
h
h
m
m
m
m
FOR DAY?
WORK BECAUSE OF
AM
AM
:
:
D
Yes
No
THIS INJURY/ILLNESS
PM
PM
E
9.(a) IS THE INJURY THE RESULT OF
(c) IF EMPLOYER'S VEHICLE, GIVE NAME AND ADDRESS OF NO-FAULT INSURANCE CARRIER.
(b) IF YES, VEHICLE IS OWNED BY:
N
THE USE OR OPERATION OF A
T
EMPLOYEE
EMPLOYER
UNKNOWN
MOTOR VEHICLE?
Yes
No
10. SEX
11. DATE OF BIRTH
12. OCCUPATION (Specific job title at which employed)
13. DATE HIRED
I
m
m
d
d
y
y
m
m
d
d
y
y
Male
N P
Female
J E
U R
14.(a) AVERAGE
(b) TOTAL EARNINGS PAID DURING 52 WEEKS PRIOR TO DATE
(b) INJURED EMPLOYEE'S WORK WEEK (Check days usually worked.)
15. (a) EMPLOYEE IS:
R S
EARNINGS PER WEEK?
OF ACCIDENT (Include bonuses, overtime, value of lodging, etc.)
Tue
Wed
Thu
Fri
Sat
Sun
Mon
Full Time
E O
0
$
,
.0
D N
$
,
.0
0
Part Time
16.WHAT WAS THE INJURY OR ILLNESS? GIVE SPECIFIC PART OF BODY AFFECTED AND HOW IT WAS AFFECTED.
(b) IF YES, WHEN?
17.(a) DID YOU PROVIDE MEDICAL
N
CARE?
Yes
No
A
T
U
18. WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM?
19. WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT?
Yes
Yes
No
No
R
20. (a) NAME AND ADDRESS OF DOCTOR
(b) NAME AND ADDRESS OF HOSPITAL
E
O
F
I
N
J
m
m
d
d
y
y
21. (a) HAS EMPLOYEE RETURNED TO WORK?
(b) IF YES, GIVE DATE:
(c) AT WHAT WEEKLY WAGE?
U
R
Yes
No
Y
$
.0
0
,
NOTE: FORM C-11 MUST BE FILED EACH TIME THERE IS A CHANGE IN EMPLOYMENT STATUS
22. WHAT WAS EMPLOYEE DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material the employee was using.)
C
A
U
S
E
O
23. HOW DID THE ACCIDENT OR EXPOSURE OCCUR? (Please describe fully the events that resulted in injury or occupational disease. Tell what happened and how it happened. Please use
F
separate sheet if necessary.)
A
C
C
I
D
24. OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE. e.g., the machine employee struck against or which struck him/her, the vapor or poison inhaled or swallowed, the chemical that
irritated his/her skin. In cases of strains, the thing (s)he was lifting, pulling, etc.
E
N
T
25. (a) DATE OF DEATH
(b) NAME AND ADDRESS OF NEAREST RELATIVE
(c) RELATIONSHIP
FATAL
m
m
d
d
y
y
CASES
DATE EMPLOYER/SUPERVISOR FIRST KNEW OF INJURY
DATE OF THIS REPORT
IF FORM IS SUBMITTED BY EMPLOYER, COMPLETE A & B BELOW. IF
m
m
d
d
y
y
P
m
m
d
d
y
y
FORM IS SUBMITTED BY THIRD PARTY, COMPLETE A,B,C & D BELOW .
R
E
A. EMPLOYEE PREPARING FORM OR SUPPLYING INFORMATION TO THIRD PARTY
B. TITLE
TELEPHONE NUMBER & EXTENSION
P
A
R
C. IF REPORT PREPARED BY THIRD PARTY, COMPANY NAME AND ADDRESS
A
T
I
O
D. THIRD PARTY CONTACT NAME
TELEPHONE NUMBER & EXTENSION
N
C-2
C-2
C-2
C-2
C-2
C-2
(11-06)

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