State of New York - Workers' Compensation Board
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE
WITH DISABILITIES WITHOUT DISCRIMINATION
Number and Street City State Zip Code
B. YOUR EMPLOYER(S)
1. Employer when injured:
3. Your work address:
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?
A. YOUR INFORMATION (Employee)
3. Mailing address:
4. Social Security Number:
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:
D. YOUR INJURY OR ILLNESS
3. Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)
If no, why were you at this location?
4. Was this your usual work location?
5. What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report) _______________________________
WCB Case Number (if you know it):
Fill out this form to apply for workers' compensation benefits because of a work injury
RUZRUNUHODWHGLOOQHVV7\SHRUprint neatly. This form may also be filled out on-line at www.wcb.ny.gov.
Number and Street/PO Box/Apartment No. City State Zip Code
7. Will you need a translator if you have to attend a Board hearing?
If yes, for what language?
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):______________________
First MI Last
5. Your supervisor's name:
2. Date of Birth: ______/______/______
5. Phone Number: (_____)_______________
2. Phone Number: (_____)_______________
4. Date you were hired: _____/_____/_____
1. Date of injury or date of onset of illness: ______/______/______
2. Time of injury:
C-3.0 (1-11) Page 1 of 2