Employee Claim - New York

No
No
D. YOUR INJURY OR ILLNESS continued
If yes, what?
No
Yes 8. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?
9. Was the injury the result of the use or operation of a licensed motor vehicle?
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?
in writing
orally
If yes, notice was given to: ____________________________________
11. Did anyone see your injury happen?
If yes, list names:________________________________________
F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS
None received (skip to question F-5)
3. Where did you receive your first off site medical treatment for your injury/illness?
none received
Doctor's office
Emergency Room
Clinic/Hospital/Urgent Care Hospital Stay over 24 hours
Name and address where you were first treated:
4. Are you still being treated for this injury/illness?
Give the name and address of the doctor(s) treating you for this injury/illness:
5. Do you remember having another injury to the same body part or a similar illness?
6. Was the previous injury/illness work related?
If yes, were you working for the same employer that you work for now?
NoYes
NoYes
Yes
NoYes
No Yes
NoYes
Yes
An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.
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.
Employee's Signature: Print Name:
On behalf of Employee: Print Name:
If yes, were you treated by a doctor?
NoYes
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:
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.
YOUR NAME:________________________________________________ DATE OF INJURY/ILLNESS: ______/______/______
Date notice given: _____/_____/_____
limited duty
E. RETURN TO WORK
1. Did you stop work because of your injury/illness?
2. Have you returned to work?
regular 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?
NoYes
NoYes
, on what date? _____/_____/_____ , skip to Section F.
If yes, on what date? _____/_____/_____
Date: _____/_____/_____
Date: _____/_____/_____
1. What was the date of your first treatment? ______/______/______
2. Were you treated on site?
Yes No
Phone Number: (_____)_______________
Phone Number: (_____)_______________
Unknown
First MI Last
C-3.0 (1-11) Page 2 of 2
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):
Print Name:
Title:
ID No., if any: R
Date: _______/_______/_______
If Licensed Representative, License No.:
Expiration Date: _______/_______/_______
Page 2/6
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