THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

STATE OF NEW YORK WORKERS’ COMPENSATION BOARD

100 BROADWAY-MENANDS ALBANY, NY 12241

(877) 632-4996

You were injured at work. What now? The New York State Workers’ Compensation Board has received notice you suffered a workplace injury or illness, so we’re preparing a workers’ compensation case in your name. You may have already received medical treatment. If you haven’t, you should seek medical care as soon as possible.

A Worker’s Responsibilities You must tell your employer, in writing, when, where and how you were injured.

Do this within 30 days of injury. Medical reports are necessary for your case. Advise your doctors that you have a work-

related injury, and give the name of your employer. Do not pay for your care yourself or use other health insurance. Tell your doctor to file reports with the Board and with your employer or its insurance carrier. If your case is disputed, the Board needs a medical report on your injury to begin resolving your claim.

Starting a Case Once your employer knows of your injury, it must notify this Board by filing a C-2 form. You should file an employee claim (C-3 form) reporting your injury as soon as possible. (You must notify the Board of your injury or illness within two years.) If you injured the same body part before, or had a similar illness, you must also file a Form C-3.3. If you haven’t already filed a C-3 or C-3.3 (if necessary), there are three ways to do it. Visit www.wcb.state.ny.us/content/main/onthejob/howto.jsp to complete the form. Complete the enclosed paper forms, and mail them to the Board. Call 1-866-396-8314. A Board employee will complete the form with you.

Health Care Bills Do not pay your doctor or hospital. Those bills are paid by the insurer unless the Board disallows your case. If your case is disputed, the providers are paid when the Board decides your case. If the Board decides against you, or if you don’t pursue a case, you will have to pay the doctor or hospital.

Your employer’s insurance covers medically necessary drugs and equipment your doctor prescribes. You’re also entitled to carfare or necessary expenses incurred when traveling for treatment. (Get receipts for those expenses.)

Claimant Information Packet

NEW YORK STATE WORKERS' COMPENSATION BOARD

Generally, you can choose any doctor authorized by the Board. You can also use occupational health clinics. However, if your employer’s insurer has a preferred provider organization to provide care for workers' compensation injuries, you must get your initial treatment from those providers. If that insurer also has a pharmacy or diagnostic network, you must get service within these networks. If the carrier uses these networks, it must also tell you its service providers and how to use them.

Benefits for Lost Wages You are entitled to a portion of your lost wages if your injury affects you in one or more ways:

1. It keeps you from work for more than seven days; 2. Part of your body is permanently disabled; 3. Your pay is reduced because you now work fewer hours or do other work.

An employer or insurer can accept your claim and begin paying your lost wage benefit promptly. Sometimes, employers and carriers dispute a claim. When that occurs, the Board strives to resolve most cases within 90 days.

You may hire an attorney or licensed representative, who can be helpful with complex or disputed claims, but it isn’t required. The Board sets their fees and they will be deducted from your lost wages award. You or your family should not pay anything directly to your attorney or licensed representative.

If your case is disputed, you may receive disability benefits while the case is heard. You’d pay them back out of your lost wages award. To get a DB-450 form, visit www.wcb.state.ny.us/content/main/forms/db450.pdf or a Board office, or call (800) 353-3092.

Help is Available People sometimes need help getting back to work. Your employer may have a return to work program that can get you back to work in light duty or an alternative position while you heal. An injury can also cause family or financial problems. The Workers' Compensation Board has rehabilitation counselors and social workers to help. Call (877) 632-4996 for more assistance.

What’s Next? Your employer or its insurance carrier will contact you if your claim is accepted. When that happens, your treatment will be paid and lost wage benefits begin. If your case is challenged, the Board will notify you about resolving the case. If more information is necessary, the Board will contact you and tell you how to file it.

Important Contact Information Workers’ Compensation Board (877)632-4996 General_Information@wcb.state.ny.us Disability Benefits (800)353-3092 www.WCB.State.NY.US NYS Bar Association Lawyer Referral and Information Service

(800)342-3661 lr@nysba.org.

C L A I M N U M B E RTHE CITY OF NEW YORK

WORKERS' COMPENSATION CLAIM INITIATION

EMPLOYEE STATEMENT

INJURED EMPLOYEE NAME SOCIAL SECURITY NUMBERFIRST NAME M.I. LAST NAME

NAME

SIGNATURE

(PLEASE PRINT) TITLE TEL.#

DATE

FISA FORM WCS-110 (1/01)

EMPLOYEE'S

ADDRESS

STREET

LOCATION

BORO, CITY

OR TOWN

APT #, FL.#,

BOX #

ZIPSTATE

DATE OF ACCIDENT / INJURY

MM DD Y YYYTIME OF ACCIDENT

AM PMH H MM:

(AREA CD)

WORK

TEL #

EXTENSION

(AREA CD)

HOME

TEL #

DATE OF STATEMENT

M DD Y YYYM# OF

WITNESS(ES)

SUPERIOR NOTIFIED

FIRST NAME M.I. LAST NAME DATE FIRST NOTIFIED

M D D Y YYYM

TITLE

(AREA CD)

WORK

TEL #

EXTENSION

DESCRIBE LOCATION WHERE ACCIDENT OCCURRED

CONTINUATION

#1 ATTACHED

DESCRIBE FULLY HOW ACCIDENT OCCURRED

CONTINUATION

#2 ATTACHED

DESCRIBE OBJECT OR SUBSTANCE THAT CAUSED INJURY

CONTINUATION

#3 ATTACHED

DESCRIBE NATURE AND EXTENT OF INJURY (INCLUDING AFFECTED BODY PARTS)

CONTINUATION

#4 ATTACHED

Chapter 1

Section B26 - Worker's Compensation

OPTION 1

Procedure: Initiate Option 1

Exhibit B26-3: Form DP2002

THE CITY OF NEW YORK

Election of rate of Charge Against Annual and /or Sick Leave Balances

for Absence Due to Injury Sustained in the Performance of Official Duties

(Pursuant to Regulation 7.0 of the Leave regulations for employees who are under the Career and Salary Plan)

INSTRUCTIONS: The injured employee, or an authorized person action in his behalf, should submit this

election notice (in duplicate) to the head of his department or agency within the first seven calendar

days of absence due to injury sustained in the performance of official duties.

I, employed in

(Print name of injured employee) (Print name of City department or agency)

in a position which is subject to the Leave regulations for employees who are under the Career and Salary Plan, or my

authorized agent, do hereby elect the option designated below, subject to the conditions attached thereto, as the one to be

applied in determining the charge, if any, to be made against my annual and/or sick leave balances for absence due to injury

sustained in the performance of my official duties.

(Check one option only)

OPTION 1: I elect to receive the difference between the amount of my weekly salary and the compensation

rate, subject to the following conditions:

(a) A pro-rated charge shall be made against my sick leave and/or annual leave balances equal to the

number of working days of absence less the number of working days represented by the Worker's

Compensation payments, and;

(b) My accrued sick leave and/or annual leave balances, or such leave credits advanced to me in accordance

with the Career and Salary Plan Leave regulations, are adequate to meet the charges made against

them for supplementary pay, and;

(c) The injury sustained by me was not the result of my willful gross disobedience of safety rules or my

willful failure to use a safety device, nor was I under the influence of alcohol, or narcotics at the time

of injury, nor did I willfully intend to bring about injury or death upon myself or another, and;

(d) Such medical examinations will be undergone by me as requested by the Worker's Compensation

Division of the Law Department and my agency, and when found fit for duty by said physicians,

I shall return to my employment.

OPTION 2: I elect to receive Worker's Compensation benefits in their entirety with no charge against sick

and/or annual leave.

Injured employee's signature

This shaded section

should be completed only

if the injured employee

cannot sign and must

designate an authorized

person to sign in his

behalf

Date

Authorized designee's name (Print)

Authorized designee's address

Witness' name (Print)

Witness' address

Witness' signature

Relationship to employee

Date

Issued 02 /15 /93 8

C L A I M N U M B E RTHE CITY OF NEW YORK - WORKERS' COMPENSATION CLAIM INITIATION

Supervisor's/Agency - "REPORT OF INJURY"

INJURED EMPLOYEE NAME EMPLOYEE IDFIRST NAME M.I. LAST NAME

(CONTINUED ON REVERSE SIDE)

EMPLOYEE'S ADDRESS

STREETLOCATION

BORO, CITYOR TOWN

APT #, FL.#,BOX #

ZIPSTATE

DATE OF ACCIDENT / INJURY TIME OF ACCIDENT

AM PM:WAS EMPLOYEE ABSENT

DUE TO INJURY?

YES NO

INITIAL ABSENCE DATE INITIAL ABSENCE TIMEAM PM:

DID EMPLOYEE FOLLOW STANDARDPROCEDURES AT TIME OF ACCIDENT?

YES NO

IF NO, DETAILSREQUIRED

CONTINUATION #3 ATTACHED

CONTINUATION #2 ATTACHED

DID EMPLOYEE'S ACTION OR BEHAVIOR CONTRIBUTE TO THE ACCIDENT?

YES NO

IF YES, DETAILSREQUIRED

CONTINUATION #4 ATTACHED

ARE DISCIPLINARY ACTIONS PENDINGOR CONSIDERED AGAINST EMPLOYEE?

YES NO

IF YES, DETAILSREQUIRED CONTINUATION

#5 ATTACHED

DOES THE AGENCY RECOMMEND TO CONTROVERT?

YES NO

IF YES, DETAILSREQUIRED

CONTINUATION #6 ATTACHED

ARE YOU AWARE OF PRE-EXISTING CONDITIONS?

YES NO

IF YES, EXPLAINCONDITION(S)

CONTINUATION #7 ATTACHED

NAMEFIRST LASTM.I.

ADDRESS STREETLOCATION

BORO, CITYOR TOWN STATE ZIP PLUS 4

NAME FIRST LASTM.I.

ADDRESS STREETLOCATION

BORO, CITYOR TOWN STATE ZIP PLUS 4 D

OCTO

R

DOC

TOR

MONTH DAY YEAR MONTH DAY YEARHOUR MINUTE

IS EMPLOYEE EXPECTEDTO RETURN TO WORK?

YES NO

INJURED WORKER'S WORK WEEKSUN MON TUE WED THU FRI SAT

(ENTER AN "X" FOR DAYS USUALLY WORKED)

HAS EMPLOYEE RETURNED TO WORK?

YES NO

RETURN TO WORK DATE

DATE NOTICE PROVIDED

SUPERVISOR'SFIRST NAME M.I. LAST NAME

TITLE (AREA CD) EXTENSIONWORK TELEPHONE #

WAS ACCIDENT ONEMPLOYER'S PREMISES?

YES NO

DID ACCIDENT OCCURDURING WORK HOURS?

YES NO

DID ACCIDENT OCCURDURING LUNCH BREAK?

YES NO

WAS EMPLOYEE TRAVELING TO/FROM WORK?

YES NO

WAS EMPLOYEE TRAVELINGBETWEEN WORK SITES?

YES NO

DID ACCIDENT OCCUR AT NORMALWORK SITE LOCATION?

YES NO

IF NO, EXACT LOCATION AND COUNTYOF ACCIDENT REQUIRED

WAS EMPLOYEE ON SPECIAL OR WORK RELATED FIELD ASSIGNMENT?

YES NO

IF YES, DESCRIBEFIELD ASSIGNMENT

CONTINUATION #1 ATTACHED

WAS INJURY WITNESSED BY SUPERVISOR? YES NO INJURY DESCRIPTION AS WITNESSED BY SUPERVISOR OR AS REPORTED MUST BE PROVIDED BELOW

MONTH DAY YEAR

MONTH DAY YEAR

HOUR MINUTE

TIME EMPLOYEE BEGAN WORK

AM PM:HOUR MINUTE

HAS THE EMPLOYEE GIVEN YOU NOTICE OF INJURY/ILLNESS?

YES NO

IF YES, NOTICE WAS GIVEN TO: ORALLY IN WRITING

WAS EMPLOYEE PAID FOR A FULL DAY ON THE DAY OF THE INJURY/ILLNESS? YES NO

MONTH DAY YEAR

UNKNOWN

NONERECEIVED

DOCTOR’SON SITE CHILD/ HOSPITAL/EMERGENCYROOM

UNKNOWNHOSPITAL STAYOVER 24 HOURS

WHO TREATED THE EMPLOYEE AND WHERE?

WHAT WAS THE DATE OF EMPLOYEE’S FIRST TREATMENT? WHERE DID THE EMPLOYEE RECEIVE FIRST MEDICAL URGENT CAREOFFICETREATMENT FOR THIS INJURY/ILLNESS?

IS THE EMPLOYEE STILL BEING TREATED FOR THIS INJURY/ILLNESS?

YES NOIF YES, PLEASE ENTER THE NAME AND ADDRESS OF TREATING DOCTOR(S) IN THE DOCTOR SECTION BELOW.

IF ACCIDENT DID NOT OCCUR AT NORMAL WORK SITE, AN EXPLANATION OF WHY EMPLOYEE WAS AT ACCIDENT SITE ISREQUIRED

TO YOUR KNOWLEDGE, DID THE EMPLOYEE HAVE ANOTHER WORK-RELATED INJURY TO THE SAME BODY PART OR A SIMILAR ILLNESS WHILE WORKING FOR YOU? YES NOIF YES, NAME THE DOCTOR(S) WHO TREATED THE PREVIOUS INJURIES/ILLNESSES (IF KNOWN):

FISA FORM WCS-100 (4/09)

INJURY DESCRIPTION (SEE CODE TABLE FOR DETAILED INJURY, CAUSE & BODY PART DESCRIPTION CODE BREAKDOWN

NATURE OF

INJURY

INJURY TYPE INJURY CODESI OD

SPECIFICINJURY

OCCUPATIONALDISEASE

DESCRIPTION

CONTINUATION #8 ATTACHED

CAUSEOF

ACCIDENT

CAUSE CODE CAUSETYPE

(CHECK ONE)

EXPOSURE(EX)

STRUCK/INJURED(SK)

FALL/SLIP(FS)

CUT/PUNCTURE(CP)

STRIKING AGAINST/STEP ON(SA)

STRAIN/INJURED (SN)

CAUGHT BETWEEN(CB)

MISCELLANEOUS CAUSE(MS)

MOTOR VEHICLE(MV)

BODY PART(S) AFFECTED (INDICATE INJURED BODY PART CODE, DESCRIPTION AND SIDE(S) AFFECTED, IF APPLICABLE) BODY SECTION

CODESBODY

SECTION

PARTCODE

BODYSECTION

PARTCODE

DESCRIPTION:LEFT

RIGHT

BOTH

DESCRIPTION:LEFT

RIGHT

BOTH

PARTCODE

PARTCODE

BODYSECTION

BODYSECTION

DESCRIPTION:LEFT

RIGHT

BOTH

DESCRIPTION:LEFT

RIGHT

BOTH

BODYSECTION

BODYSECTION

DESCRIPTION:LEFT

RIGHT

BOTH

DESCRIPTION:LEFT

RIGHT

BOTH

EMPLOYEE'S JOB DESCRIPTION

JOB TASKAT TIME

OF INJURY

FUNCTIONAL TITLE & DESCRIPTION (ATTACH JOB DESCRIPTION IF AVAILABLE)TYPICAL

WORKDAY

(8 HR. MAX.)

SITTING STANDING WALKING

:

TYP

ICA

L W

OR

KD

AY T

AS

KS

INDI

CATE

WO

RKDA

Y AC

TIVI

TY % ACTIVITY

BENDING / SQUATTING

CLIMBING

KNEELING

LIFTING * Complete LiftingDetail Section

REACHING ABOVE SHOULDER

PUSH / PULL

0 %(N / A)

A

A

A

10 %(MINIMAL)

B

B

C

C

C

20 %(OCCASIONAL)

D

D

D

35 %(MODERATE)

E

E

E

50 %(FREQUENT)

F

F

F

F

70 - 100 %(CONTINUOUS) *LIFTING

UP TO 10 POUNDS

11 TO 20 POUNDS

21 TO 30 POUNDS

31 TO 50 POUNDS

OVER 50 POUNDS

0 %(N / A)

A

A

A

A

A

B

B

B

B

B

C

C

C

C

C

20 %(OCCASIONAL)

D

D

D

D

D

35 %(MODERATE)

E

E

E

E

E

50 %(FREQUENT)

F

F

F

F

F

70 - 100 %(CONTINUOUS)

F

FA

A

B

B

B

C

C

C

D

D

D

E

E

EA B

LIFT

ING

DETA

ILS

IS KEYBOARD USED?

YES NO IF YES,HOW MANY HRS

PER WEEK?

ARE HANDS USED FOR NON KEYBOARD REPETITIVE MOTION?

YES NO IF YES, EXPLAIN WHAT OTHER REPETITIVE MOTIONS ARE PERFORMED?

DID ACCIDENT INVOLVE A MOTOR VEHICLE? YES NO IF YES, WAS VEHICLE REGISTERED TO

THE CITY OF NEW YORK?YES NO USE OF CITY

VEHICLE AUTHORIZED?YES NO EMPLOYEE STRUCK

BY CITY VEHICLE?YES NO EMPLOYEE DRIVING

A CITY VEHICLE?YES NO

WAS EMPLOYEE AVEHICLE PASSENGER?

YES NOWAS INJURED ON PUBLICTRANSPORTATION?

YES NO

DID EMPLOYEE DIE FROM INJURY?IF YES, ANSWER THE FOLLOWING QUESTIONS

YES NO DATEEMPLOYEE DIED

TIME EMPLOYEE DIED

AM PM:NAME OF NEARESTRELATIVE

FIRST M.I. LAST NAME

RELATIONSHIPHOME

TELEPHONE #

ADDRESS STREET LOCATION(INCLUDE APT/FL#)

BORO, CITYOR TOWN

IDENTIFY PERTINENT DOCUMENTATION(e.g. Police Report, Safety Reports, etc.)

CONTINUATION #10 ATTACHED

WAS INJURY CAUSED BY ASSAULT ON THE JOB? YES NO IF YES, PROVIDE INFORMATION BELOW

ASSAILANT WAS: CO - WORKEROFFENDER

FRIEND, FAMILY OR ACQUAINTANCEOWNER / OPERATOR

CLIENTOUTSIDE CONTRACTOR

OTHER

ASSA

ULTE

D BY NAME OF

ASSAILANTFIRST M.I. LAST NAME

ADDRESS STREET LOCATION(INCLUDE APT/FL#)

BORO, CITYOR TOWN

HOMETELEPHONE #

WORKTELEPHONE #

CAN YOU PROVIDE DETAILED EVENTS PRECEDING ASSAULT?

YES NO

IF YES,EXPLAIN

DID ASSAULT INVOLVEA PERSONAL MATTER?

YES NO

IF YES,EXPLAIN

CONTINUATION #11 ATTACHED

CONTINUATION #12 ATTACHED

DID ASSAULT INVOLVEWORK RELATED MATTER?

YES NO

IF YES,EXPLAIN

CONTINUATION #13 ATTACHED

DID THE EMPLOYEE START,PROVOKE OR PROLONG THE

ASSAULT IN ANY WAY?YES NO

IF YES,EXPLAIN

CONTINUATION #14 ATTACHED

PREPARED BY(Please Print)

SIGNATURE

TITLE

TEL #DATE

HN(HEAD/NECK)

UE(UPPER)

TR(TRUNK)

LE(LOWER)

DESCRIPTION CONTINUATION #9 ATTACHED

CONTINUATION #12 ATTACHED

:

EXTENSION

INDICATE THE PERCENTAGE OF WEIGHT LIFTED PER CATEGORY DURING A TYPICAL WORKDAY

IF YES,EXPLAIN

PARTCODE

PARTCODE

10 %(MINIMAL)

:HOUR MINUTE HOUR MINUTE HOUR MINUTE

DOES EMPLOYEE OWNTHE VEHICLE?

YES NO

EMPLOYEE’S JOBWAS (CHECK ONE):

FULL TIME

PART TIME

ADDITIONAL INFORMATION:

WAS AN OBJECT (E.G HAMMER, ACID) INVOLVED IN THE INJURY/ILLNESS? YES NOIF YES, WHAT WAS IT?

YES NOIS CLAIMANT A SEASONAL EMPLOYEE?

STATE ZIP PLUS 4

STATE ZIP PLUS 4

MONTH DAY YEAR HOUR MINUTE

C L A I M N U M B E RTHE CITY OF NEW YORKWORKERS' COMPENSATION CLAIM INITIATION

WITNESS STATEMENTINJURED EMPLOYEE NAME SOCIAL SECURITY NUMBER

FIRST NAME

FIRST NAME

M.I. LAST NAME

LAST NAMEW I T N E S S I N F O R M AT I O N

M.I.

STREET LOCATION (INCLUDE APT / FL #)

STATE ZIP PLUS 4

(AREA CD) (AREA CD)

HOMEADDRESS

BORO, CITYOR TOWN

WORK TEL # HOME TEL#

ARE YOU A CITY

EMPLOYEE?

YESNO

RELATIONSHIP TO INJURED DATE OF ACCIDENT / INJURY TIME OF ACCIDENT

AM PM

LIST OTHER PERSONS

WHO ALSOMIGHT HAVE WITNESSED ACCIDENT

ATTACH NAMES OFADDITIONALWITNESSES

CONTINUATION ATTACHED

FIRST NAME M.I. LAST NAME

DESCRIPTION OF ACCIDENT - INCLUDING LOCATION

NAME

SIGNATURE

(PLEASE PRINT) TITLE

CONTINUATION ATTACHED

TEL.#

DATE

FISA FORM WCS-120 (8/00)

:MONTH DAY YEAR HOUR MINUTE

SOCIAL SECURITY NUMBER