Workers’ Compensation Board Common Forms Title Small -->

If you require assistance with completing these forms, please contact us.

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it. Please enter your information, select print and choose Microsoft Print to PDF and submit the saved PDF. Please note, that if you do not Print to PDF, the entered data may not be transmitted resulting in a blank form being submitted. If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. If you still have trouble with the form, please email the Board's Forms Department.

Multi-page Forms
Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.

Certificates of Insurance
Forms C-105, C-105.1, C-105.2, DB-120, DB-120.1 and DB-155 are not available on this site. Contact your insurance carrier or licensed NYS insurance agent for these forms..

C-4 Medical Billing Forms
All versions of the C-4 medical billing forms (except the C-4.3) were replaced by the required submission of the CMS-1500 form on July 1, 2022. Learn more about the CMS-1500 Initiative

Current Versions of Forms
WCB periodically releases new versions of certain forms to obtain additional information, streamline processing, and/or make it easier to complete the form. These changes are often extensive, and it is important for all stakeholders to use the same form so that information is consistent. As such, WCB may announce that it will not accept older versions of an updated form after a certain date. The table below has the most recent version of each form, and where older versions are no longer accepted, includes the notation "Only current version accepted."

RFA-2 and other Board form updates – December 2023
The Request for Further Action by Insurer/Employer (Form RFA-2) has been modified to better align with the process for resolving payer denials of the Workers' Compensation Board's New York Medical Treatment Guidelines (MTGs) Variance and MTG Special Services Prior Authorization Requests (PARs).

Additionally, the Board will no longer be accepting older versions of several forms. Read more in a notification dated December 4, 2023.

Original Signature Requirement

COVID-19 Response: Original Signature Requirement Relief – March 2020

The Workers' Compensation Board does not normally accept a claimant's electronic signature on Board-prescribed forms. Due to recent increases in COVID-19 infection rates across New York State, however, as of August 16, 2021, the Emergency Relief from Signature Requirements on Listed Documents will remain in effect until further notice for the forms specifically listed in the Board's announcement: Emergency Relief from Original Signature Requirements on Listed Documents.

The Board, as standard practice, does not accept electronic signatures on Board-prescribed forms, as the Board is unable to efficiently evaluate the electronic signature process used by an insurer, health care provider, attorney, or licensed representative to ensure that the procedure complies with the New York Electronic Signatures and Records Act (ESRA) and applicable regulations. Therefore, a claimant's ink signature must be supplied when a claimant's signature is required by law.

Common Workers' Compensation Board Forms

[C-3 Online Submission] Employee Claim Employee Workers' Compensation Board, in the event of on-the-job injury or illness. Within two years of accident, or within two years after employee knew or should have known that injury or illness was related to employment.

[C-4 Online
Submission]

As of 7/1/22, CMS-1500 should be used.

To report continued treatment, use Form C-4.2.

As of 7/1/22, CMS-1500 should be used.

As of 7/1/22, CMS-1500 should be used.

[EC-4 AMR Online
Submission]

As of 7/1/22, CMS-1500 should be used.

As of 7/1/22, CMS-1500 should be used.

Information on the CMS-1500 Initiative Doctor's Narrative Report Health Care Provider Workers' Compensation Board, insurer, injured employee or employee's representative Use this form to report first treatment; for the 15 day report after first treatment; and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart. services. To report permanent impairment use Form C-4.3.

As of 7/1/22, CMS-1500 should be used.

Information on the CMS-1500 Initiative Attending Ophthalmologist's Report Health Provider Workers' Compensation Board, insurance carrier, injured employee or employee's representative 48 hour initial report, within 48 hours of first treatment.

15 day report, after treatment is first rendered.

The Board will only accept the current version of this form.

[C-8.1B Online Submission] Notice of Objection to a Payment of a Bill for Treatment Provided Insurance Carrier/Board-approved self-insurer Workers' Compensation Board, copy to employee and employee's representative, and health provider Treatment issue: within 5 days after terminating medical care or refusing authorization.

Disputed bill: within 45 days of submission of bill.

When submitting the objection forms C-8.1B and C-8.4 with supporting attachments in the same submission, the attachments will be placed behind the C-8.1B and the C-8.4 will be processed as a single document. If attachments are required behind both the C-8.1B and the C-8.4, please submit these two forms separately from each other with their corresponding attachments.

The Board will only accept the current version of this form.

05/03/2022 – Form C-8.4 Updates Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) Carrier/Self-Insured Employer Health Care Provider, Workers' Compensation Board, Claimant and employee's representative, if any This form must be used for valuation objections except when the amount billed for the particular CPT code is in excess of the amount designed by the workers' compensation fee schedule, and the insurer pays the bill at the appropriate fee schedule amount.

As of October 19, 2024, the Board will only accept the current version of this form.

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029

If you became sick or disabled after having been unemployed for more than four (4) weeks, file with:

As of 3/7/22, this is no longer a paper form and all requests are to be submitted via OnBoard.

To report response to a request for information - file within 10 days of submission of response.

The Board will only accept the current version of this form.

New Fee Application Desk Aid Application for a Fee by Claimant’s Attorney or Licensed Representative Attorney/Licensed Representative Workers’ Compensation Board, copy to the claimant. When fee of more than $1,000 is requested.

The Board will only accept the current version of this form. Attorney/Representative's Certification of Form C-3 or Notice of Controversy Attorney/Licensed Representative Workers' Compensation Board, copy to all other parties of interest. Claimant's Attorney/Representative: Within 5 days after you have been retained by a claimant who has previously filed Form C-3 without your certification.

As of 7/1/22, CMS-1500 should be used.

Information on the CMS-1500 Initiative Occupational/ Physical Therapist's Report Occupational/ Physical Therapist Workers' Compensation Board, insurer, referring doctor, injured employee or employee's representative 48 hour initial report, within 48 hours of first treatment.

15 day report, after treatment is first rendered.

As of 7/1/22, CMS-1500 should be used.

Information on the CMS-1500 Initiative Psychologist's Report Psychologist Workers' Compensation Board, insurer, injured employee or employee's representative 48 hour initial report, within 48 hours of first treatment.

15 day report, after treatment is first rendered.

-Date lost time (intermittent or continuous) exceeds 12 weeks.

* Translations of the 4/24 version of these forms are in progress and will be posted when completed. Questions? Email LanguageAccessCoordinator@wcb.ny.gov.

* Translations of the 4/24 version of these forms are in progress and will be posted when completed. Questions? Email LanguageAccessCoordinator@wcb.ny.gov.

* Translations of the 4/24 version of these forms are in progress and will be posted when completed. Questions? Email LanguageAccessCoordinator@wcb.ny.gov.

The Board will only accept the current version of this form.

04/29/2022 - RFA Process Updates Request for Further Action by Legal Counsel Claimant's Representative Workers' Compensation Board, with copy to employer's insurance carrier or directly to employer or third-party administrator if employer is a Board-approved self-insurer. The form may be filed at any time after the assembly or indexing of a claim or after the Board has indicated that no further action (NFA) will be taken.

[RFA-1W Online Submission] Request for Assistance by Injured Worker Claimant Workers' Compensation Board The form may be filed at any time after the Board assigns a WCB case number, or any time after the Board has indicated that no further action (NFA) will be taken.

The Board will only accept the current version of this form.

04/29/2022 - RFA Process Updates Request for Further Action by Insurer/Employer Insurance Carrier or Board-approved self-insured employer Workers' Compensation Board, with copies to claimant and claimant's representative, if any. The form may be filed at any time after the assembly or indexing of a claim or after the Board has indicated that no further action (NFA) will be taken.

Executive Officer must authorize appropriate medical examination within 8 hours of receipt of Form VF/VAW-11C. Contact the nearest office of the Workers' Compensation Board if authorization is not granted within that time.

If the form you are looking for is not listed above, or in the list of Common Board Forms, please email the Board's Forms Department.

Workers’ Compensation Board