EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE IN EMPLOYMENT STATUS RESULTING FROM INJURY

EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE IN
EMPLOYMENT STATUS RESULTING FROM INJURY

EC-11

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

If you have used the previous version of this form, please be aware that some functions such as Saving Data and Loading Previously Saved Data have changed. Please read Form Instructions for additional information.

This report is to be filed directly with the Chair, Workers' Compensation Board as soon as the employment status of an injured employee, as reported on First Report of Injury, or on a previous Form C-11 or EC-11, is changed. Change in employment status includes return to work, discontinuance of work, increase or decrease of regular hours of work and increase or reduction of wages. A copy should also be sent to your insurer.

Required items are indicated by an *

A. Case Information - ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS

* Date of Injury/Illness:

WCB Case #: (if known)

Claim Administrator Claim (Carrier Case)#:

B. Employee Information

* Last Name: * First Name: MI:

* Mailing Address:

Line 2:

* City: State: Zip Code: Country:

* Daytime Phone #:

Email Address:

Social Security #:

* Date of Birth:

Gender:

M F X

« Prev Page Next Page »

C. Employer Information

* Employer Name:

* Mailing Address:

Line 2:

* City: State: Zip Code: Country:

* Employer Phone #

* Federal Tax ID #:

The Tax ID # is the (select one):

SSN EIN

« Prev Page Next Page »

D. Insurer Information

* Insurer Name:

* Insurer ID (W #):

* Mailing Address:

Line 2:

* City: State: Zip Code: Country:

* Insurer Phone #:

« Prev Page Next Page »

E. Details

* Date of first full day employee lost from work:

Date employee first returned to work:

Loss of time resulting from the above injury since initial date of lost time:
Loss of Time Start Date	Return to Work Date	Reason
Loss of Time Start Date	Return to Work Date	Reason

As a result of the above injury, was there an increase or decrease in hours worked or wages paid?

Yes No

If yes, enter status of change below:
Employment Status	Effective Date	Hours per Day	Days per Week	Earnings	Remarks
Prior to Injury	Effective Date	Hours per Day	Days per Week	Earnings	Remarks
Changed To	Effective Date	Hours per Day	Days per Week	Earnings	Remarks

« Prev Page Next Page »

F. Sign

An employer or insurer, or any employee, agent, or person acting on behalf of an employer or insurer, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

* Last Name: * First Name: MI:

Employer Name:

Official Title:

* Phone #:

* Email Address:

« Prev Page

Workers’ Compensation Board Home

Online Form Submission

State of New York - Workers' Compensation Board

Workers’ Compensation Board Home