Before you can receive workers’ compensation benefits in New York, you must complete the Employee Claim form, also known as the C-3 form. This step is separate from notifying your employer about your injury. The C-3 form is a claim for workers’ compensation benefits that you send directly to the New York Workers’ Compensation Board.
Your information must be complete and accurate to avoid delays or an unwarranted denial. The C-3 form is available on the New York State Workers’ Compensation Board’s website. Our award-winning New York workers’ compensation lawyers can help you with all the steps to complete the C-3 form.
Guide to Filling Out a Workers' Compensation Form
The instructions below will guide you in completing each section of the form.
I. Personal Information (Section A)
Section A is for your basic personal information, including your name, address, gender, and Social Security number. Use your full legal name and the address where you receive mail.
Workers’ compensation only asks for this information to identify you. You are entitled to receive workers’ compensation regardless of your immigration status when you are injured at work. If you do not have a Social Security number, leave this space blank. This section also provides a space to list your preferred language if you do not speak English and will require a translator.
II. Employer Information (Section B)
Section B is where you provide the Workers’ Compensation Board with the information necessary to identify your employer. You will need the following information:
- Your employer’s name and phone number
- Your work address
- Your hire date
- Your supervisor’s name
- The names and addresses of any other employers at the time you were injured
III. Employment Details (Section C)
In Section C, you must tell the Workers’ Compensation Board your job title, the type of work you do, the nature of your employment, and details about your pay when you are working.
IV. Injury/Illness Details (Section D)
Section D is the portion of the form that requires you to provide details about how the accident happened and the injury or illness you suffered as a result. You must provide the following information:
- The date and time the accident occurred.
- The address and approximate location where the injury occurred.
- Whether the location was your normal work location and, if not, why you were there.
- The job duties you were performing when you were injured.
- How your injury occurred.
- A description of your injury or illness, including what body parts were injured.
- Whether an object, such as heavy machinery or a tool, was involved.
- Whether a motor vehicle was involved and the tag number, if you have it.
- Your insurance information if your vehicle was involved.
- Whether you gave your employer notice of the injury, on what date, and whether verbally or in writing.
- Whether there were any witnesses to your accident.
V. Work Pause (Section E)
In Section E, you must tell the Workers’ Compensation Board whether you stopped work because of your injury and for how long. You will need to provide the date on which you stopped working because of your injury and whether you have returned to work (include the date). Also, provide your pay rate upon returning and whether you switched employers.
VI. Medical Treatment (Section F)
In Section F, you must provide information about any medical treatment you have received for your injuries, including the following:
- Date and location where you received your initial treatment and the provider’s name and address.
- Whether you are still receiving treatment and your providers’ names and addresses.
- Whether you have a history of injuries to the same body part or similar illnesses, along with the names and addresses of any doctors who treated you.
If your answer to the last question is yes, you must also complete a Limited Release of Health Information (HIPAA) form authorizing your previous health care providers to provide relevant information to the Board.
VII. Filing the C-3 Form
You can download a printable version of the C-3 form. You can mail your completed form or submit it online. You must file the form within two years of your accident date. When completing the form, answer every question. Provide complete and accurate answers, but avoid providing more information than the form requests. If a question does not apply to you, write “not applicable” or N/A rather than leaving it blank.
Shulman & Hill Can Help You With Your C-3 Form
We have extensive experience helping injury victims receive workers’ compensation benefits in New York. Founding partner Alex Shulman is also a member of the New York Injured Workers Bar Association.
We can help you file your C-3 form, ensuring it is complete and accurate so you receive your benefits as soon as possible. Call (212) 221-1000 or contact us online to schedule your free consultation with our knowledgeable workers’ compensation attorneys today.
