Employee Claim 
                                                                                                      State of New York  -Workers' Compensation Board                                                 C-3
                                       ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` `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 www.wcb.ny.gov.
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/Apartment No.                                                                     City                              State     Zip Code
4. Social Security Number:                                                                            -           -       5. Phone Number: (_____)_______________            6. Gender:   M   F       X
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)
1. Employer when injured:                                                                                                                                        2. Phone Number: (_____)_______________

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?                                                                           Yes     No  If yes, describe:

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):______________________

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                                                                                                                                                                                    C-3.0 6-22

       YOUR NAME:________________________________________________First                                           MI            Last     DATE OF INJURY/ILLNESS: ______/______/______
D. YOUR INJURY OR ILLNESS             continued
      8. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?                                               Yes     No  If yes, what? 
      9. Was the injury the result of the use or operation of a licensed motor vehicle?                                                 Yes     No
        If yes,         your vehicle           employer's vehicle                 other vehicle                                     License plate number (if known):
        If your vehicle was involved, give name and address of your motor vehicle insurance carrier:

10. Have you given your employer (or supervisor) notice of injury/illness?                                                          Yes     No
         If yes, notice was given to: ____________________________________                                                          orally  in writing Date notice given: _____/_____/_____

11. Did anyone see your injury happen?                      Yes           No  Unknown     If yes, list names:________________________________________

E. RETURN TO WORK
      1. Did you stop work because of your injury/illness?                   Yes, on what date? _____/_____/_____                    No, skip to Section F.

      2. Have you returned to work?            Yes          No            If yes, on what date? _____/_____/_____                                         regular duty    limited duty
      3. If you have returned to work, who are you working for now?                  Same employer                                            New employer                Self employed
      4. What is your gross pay (before taxes) per pay period?                                                                             How often are you paid?
F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS
      1. What was the date of your first treatment? ______/______/______                                                              None received (skip to question F-5)
      2. Were you treated on site?    Yes                   No
      3. Where did you receive your first off site medical treatment for your injury/illness?                                                none received          Emergency Room
                     Doctor's office                        Clinic/Hospital/Urgent Care                                                    Hospital Stay over 24 hours 
        Name and address where you were first treated:
                                                                                                                                                  Phone Number: (_____)_______________
      4. Are you still being treated for this injury/illness?                Yes     No
       Give the name and address of the doctor(s) treating you for this injury/illness:
                                                                                                                                                  Phone Number: (_____)_______________
      5. Have you had another injury to the same body part, or a similar illness?                                                           Yes        No 
         If yes, were you treated by a doctor?              Yes           No        If yes, provide the names and addresses of the doctor(s) who treated 
        you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM:

      6. Was the previous injury/illness work related?                    Yes     No
        If yes, were you working for the same employer that you work for now?                                                       Yes     No
I am hereby making a claim for benefits under the Workers' Compensation Law.  My signature affirms that the information I am providing is true 
and accurate to the best of my knowledge and belief. 
       Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it 
       will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any 
       material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.
Employee's Signature:                                                         Print Name:                                                                           Date: _____/_____/_____
On behalf of Employee:                                                        Print Name:                                                                           Date: _____/_____/_____
An individual may sign on behalf of the employee only if they are legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated. 
I certify to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the allegations and other factual 
matters asserted above have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery.
Signature of Attorney/Representative (if any):                                                                                                                Date: _______/_______/_______
Print Name:                                                                               Title: 
ID No., if any:  R                             If Licensed Representative, License No.:                                                                Expiration Date: _______/_______/_______
C-3.0 (6-22)  Page 2 of 2

Instructions for Completing Employee Claim (Form C-3)  
Please complete this form and send it to the Workers' Compensation Board centralized mailing address listed at the end of these 
instructions. If you need additional help completing this form, contact the Workers' Compensation Board at 1-877-632-4996. You 
may also fill this form out online at wcb.ny.gov. If you do not have or know your Workers' Compensation Board Case Number, 
please leave this field blank. It is not required to process your claim. Remember to enter your name and the date of your injury/
illness on the top of page two.  
 
Section A - Your Information (Employee):  
In Section A, enter your name, address and other requested information.   
Note on Item 7: Board hearings are conducted in English. If you need a translator, select Yes and indicate the language needed. 
 
   Notification Pursuant to the New York Personal Privacy Protection Law  
   (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. § 552a).   
    
   The Workers' Compensation Board's (Board’s) authority to request that claimants provide personal information, including their 
   social security number, is derived from the Board’s investigatory authority under  Workers' Compensation Law (WCL) § 20, and 
   its administrative authority under WCL § 142. This information is collected to assist the Board in investigating and administering 
   claims in the most expedient manner possible and to help it maintain accurate claim records.  Providing your social security 
   number to the Board is voluntary. There is no penalty for failure to provide your social security number on this form; it will not 
   result in a denial of your claim or a reduction in benefits.  The Board will protect the confidentiality of all personal information in 
   its possession, disclosing it only in furtherance of its official duties and in accordance with applicable state and federal law. 
    
Section B - Your Employer(s):  
In Section B, enter the name, address, phone number and other information of the employer you were working for at the time of the 
injury/illness.   
Note: Your employer is the company or agency that issues your paycheck. If you are a contractor at a work site or office, the staffing 
agency or vendor who hired you is your employer, not the work site or office where you report to work.   
 
Section C - Your Job on the Date of the Injury or Illness:  
In Section C, enter your job title, work activities and pay information.  
 
Section D - Your Injury or Illness:  
In Section D, enter your injury or illness information.  
Item 1: Enter the date you were injured or the first date you noticed you became ill.   
If this is an illness or occupational disease, skip item 2. The date you were injured must be in month/day/year format. The year 
should be written as four digits, e.g., 2015.   
Item 2: Enter the time when the injury occurred. Check whether it was AM or PM.  
Item 3: Indicate the location where the injury/illness occurred, including the address of the building and the physical location in the 
building where the injury/illness happened.  
Item 4: Check whether this was your normal work location. If it was not, explain why you were at this location.  
Item 5: Describe in detail what you were doing at the time of the injury/illness (e.g., unloading boxes from a truck by hand). This 
explains the events leading up to the injury.  
Item 6: Describe in detail how the injury/illness occurred (e.g., I was lifting a heavy box off a truck). This should include all people 
and events involved in the injury/illness.  
Item 7: Indicate fully the nature and extent of your injury/illness, including all body parts injured. Be as specific as possible (e.g., I 
strained my back trying to lift a heavy box. It hurts to bend over or hold even lighter objects now).  
Item 8: Indicate if some object was involved in the accident other than a licensed motor vehicle. Other objects may include a tool 
(e.g., hammer), a chemical (e.g., acid), machinery (e.g., forklift or drill press), etc.  
Item 9: Indicate if a licensed motor vehicle was involved in the accident. If so, check if the motor vehicle involved was yours, your 
employer's, or a third party's. Include the license plate number (if known). If your vehicle was involved, fill out the name and address 
of your automobile liability insurance carrier. If you filed a Department of Motor VehiclesForm MV-104 (Report of Motor Vehicle 
Accident), please submit a copy along with the C-3. This will expedite the process for you to receive potential benefits. 
Item 10: Check if you gave your employer or supervisor notice of your injury or illness. If so, indicate who you gave notice to as well 
as if it was orally or in writing. Include the date you gave notice.  
Item 11: Check if anyone else saw the injury happen. If anyone did see it, include their name(s).  
 
Section E - Return to Work:  
Item 1: If you stopped working as a result of your work-related injury/illness, check Yes and indicate the date you stopped working. If 
you have not stopped working, check No and skip to the next section.  
Item 2: If you have since returned to work, check Yes. Also indicate on what date you started working again, as well as if you have 
returned to your Normal Duties or if you are on Limited or Restricted Duty. (If you have not returned to your full pre-injury or illness 
work duties, then you are on Limited Duty.)  
Item 3: If you have returned to work, indicate who you are working for now.  
Item 4: Enter your gross pay (before tax pay) per pay period for the job you are working at now. Indicate how often you are receiving 
a paycheck (weekly, bi-weekly, etc.). 

C-3.0 (6-22) 

Section F - Medical Treatment for This Injury or Illness:  
Item 1: If you did not receive medical treatment for this injury/illness, check None Received and skip to item 5. Otherwise, enter the 
date you first received treatment for this injury/illness and complete the rest of this section.  
Item 2: Check if you were first treated on the job for this injury or illness.  
Item 3: Check the location where you first received off site medical treatment for your injury or illness. Include the name and  
address of the facility as well as the phone number (including area code).  
Item 4: If you are still receiving ongoing treatment for the same injury or illness, check Yes and indicate the name and address of  
the doctor(s) providing treatment as well as the phone number (including area code); otherwise, check No.  
Item 5: If you already had an injury to the same body part or a similar illness, check Yes and indicate if you were treated by a doctor 
for this injury or illness. If you were treated by a doctor, indicate the name(s) and address(es) of the doctor(s) whom provided care 
and complete and file Form C-3.3 together with this form. 
Item 6: If you had a previous injury or illness, check if your previous injury or illness was work-related. If Yes, check if the injury or 
illness happened while working for your current employer.  
 
Sign Form C-3 in the place provided for Employee's Signature on page 2, print your name, and enter the date you signed the form. 
If a third-party is signing on behalf of the employee, that person should sign on the second signature line. If you have legal 
representation, your representative must complete and sign the attorney/representative's certification section on the  
bottom of page 2.  
 
What Every Worker Should Do in Case of On-The-Job Injury or Occupational Disease:  
1. Immediately tell your employer or supervisor when, where and how you were injured. 
2. Secure medical care immediately. 
3. Tell your doctor to file medical reports with the Board and with your employer or its insurance carrier. 
4. Make out this claim for compensation and send it to the nearest Workers' Compensation Board Office. (See below.) Failure to file 
within two years after the date of injury may result in your claim being denied. If you need help in completing this form, telephone or 
visit the nearest Workers' Compensation Board Office listed below. 
5. Go to all hearings when notified to appear. 
6. Go back to work as soon as you are able; compensation is never as high as your wage. 
 
Your Rights:  
1. Generally, you are entitled to be treated by a doctor of your choice, provided they are authorized by the Board. If your employer is 
involved in a preferred provider organization (PPO) arrangement, you must obtain initial treatment from the preferred provider 
organization which has been designated to provide health care services for workers' compensation injuries. 
2. DO NOT pay your doctor or hospital. Their bills will be paid by the insurance carrier if your case is not disputed. If your case is 
disputed, the doctor or hospital must wait for payment until the Board decides your case. In the event you fail to prosecute your case 
or the Board decides against you, you will have to pay the doctor or hospital. 
3. You are also entitled to be reimbursed for drugs, crutches, or any apparatus properly prescribed by your doctor and for carfares 
or other necessary expenses going to and from your doctor's office or the hospital. (Get receipts for such expenses.) 
4. You are entitled to compensation if your injury keeps you from work for more than seven days, compels you to work at lower 
wages, or results in permanent disability to any part of your body. 
5. Compensation is payable directly and without waiting for an award, except when the claim is disputed. 
6. Injured workers or dependents of deceased workers may represent themselves in matters before the Board or may retain an 
attorney or licensed representative to represent them. If an attorney or licensed representative is retained, their fee for legal services 
will be reviewed by the Board and if approved will be paid by the employer or insurance company out of any compensation benefits 
due. Injured workers or dependents of deceased workers should not directly pay anything to the attorney or licensed representative 
representing them in a compensation case. 
7. If you need help returning to work, or with family or financial problems because of your injury, contact the Workers' Compensation 
Board office nearest you and ask for a rehabilitation counselor or social worker. 
 
This form should be filed by sending directly to the address listed below:  
New York State Workers' Compensation Board  
Centralized Mailing  
PO Box 5205 Binghamton, NY 13902-5205  
 
Customer Service Toll-Free Number: 877-632-4996 

C-3.0 (6-22)