Forms Submitted by Attorneys and Licensed Representatives

Form Number	Form Title	Registration required?	Comments
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04).
RFA-1LC	Request for Further Action By Legal Counsel	No	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. Note: When filing required documents (e.g., medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name, and date of injury.
VDF-1	Loss of Wage Earning Capacity Vocational Data Form	No	Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

 

Forms Submitted by Employers

Form Number	Form Title	Registration required?	Comments
C-11	Employer's Report of Injured Employee's Change in Employment Status Resulting From Injury	No	As soon as employment status of injured employee changes.
C-240	Employer's Statement of Wage Earnings	No	Within 10 days of request by the Board.
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04).
RFA-2|	Request for Further Action By Insurer/Employer	No	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. Note: When filing required documents (e.g., medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name, and date of injury.

 

Form Submitted by Health Care Providers

Form Number	Form Title	Who Can Submit?	Comments
C-4.3	Doctor's Report of MMI/Permanent Impairment	Physician Chiropractor Podiatrist Psychologist Nurse Practitioner Licensed Clinical Social Worker	Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment.

Please Note: 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.

To submit the web version of the C-4.3, the health care provider must be authorized by the NYS Workers' Compensation Board.

Forms Submitted by Injured Workers

Form Number	Form Title	Registration required?	Comments
C-3	Employee Claim	No	Must be filed within two years of injury, or within two years after employee knew or should have known that injury or illness was related to employment.
RFA-1W|	Request for Assistance By Injured Worker	No	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. Note: When filing required documents (e.g., medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder.
VDF-1	Loss of Wage Earning Capacity Vocational Data Form	No	Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

 

Forms Submitted by Insurance Carriers, Self-Insured Employers
and Third-Party Administrators

Form Number	Form Title	Registration required?	Comments
C-8.1B	Notice of Objection to a Payment of a Bill for Treatment Provided	Yes	Treatment issue: within 5 days after terminating medical care or refusing authorization. Disputed bill: within 45 days of submission of bill.
DB-470	Preliminary/Final Claim for Reimbursement of Benefits Paid Under Disability Benefits Law	Yes	Submitted prior to award of workers' compensation benefits.
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04).
RFA-2|	Request for Further Action By Insurer/Employer	No	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. Note: When filing required documents (e.g., medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name, and date of injury.

If the form you are looking for is not available for online submission, you may print the PAPER version of the form from our list of common forms.