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WC & DBL Forms

NYS Workers’ Compensation & DBL Common Forms

Workers’ Compensation:

  • C-2 Employers Report of Accident
  • C-3 Employee’s Claim for Compensation
  • C-11 Employer’s Report of Injured Employee’s Change in Status or Return to Work
  • C-22 Application for Approval of Non-Schedule Adjustment
  • C-32 Settlement Agreement
  • C-105.51 Notice of Election of a Corporation Which is Required to Have Coverage for its Employees Under The New York State Workers’ Compensation Law to Exclude the Sole Shareholder-Officer or One of the Two or Both Executive Officers-Shareholders of the Corporation from Such Coverage
  • C-121 Claim for Compensation and Notice of Commencement of Third Party Action
  • C-240 Employer’s Statement of Wage Earnings Preceding Date of Accident
  • C-257 Claimant’s Record of Medical and Travel Expenses

New York State Disability

  • 102 Information for Employer Regarding Disability Benefits Law
  • DB 125 Employer Identification Card
  • DB 212.5 Notice of Election To Voluntarily Exclude Spouse from Coverage
  • DB 300 Notice of Proof of Claim for Disability Benefits By Unemployed Claimant
  • DB 450 Notice and Proof of Claim for Disability Benefits
  • DB 791 Reference Table of Employee Contributions By Pay Period For Employer Use