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Employer's First Report of Work Related Injury Form

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STATE OF NEW YORK - WORKERS' COMPENSATION BOARD
EMPLOYER'S REPORT OF WORK-RELATED ACCIDENT/OCCUPATIONAL DISEASE

Send this notice directly to the Chair, Workers' Compensation Board at the address shown on the reverse side within ten (10) days after an accident occurs. ANSWER ALL QUESTIONS FULLY. A copy should also be provided to or retained by your workers' compensation insurance carrier.

Any employer who fails to timely file Form C-2, as required by Section 110 of the Workers' Compensation Law, is subject to a fine of not more than $1,000. In addition, the Board or Chair may impose a penalty of up to $2,500.

TYPEWRITER PREPARATION IS STRONGLY RECOMMENDED - INCLUDE ZIP CODE IN ALL ADDRESSES - EMPLOYEE'S S.S. NO. MUST BE ENTERED BELOW

WCB Case No. (If Known)

Carrier Case No.

Carrier Code No.

WC Policy No.

Date of Accident

Employee's S.S. No.

1(a). Employer's Name

1(b). Employer's Mailing Address

1(c). OSHA Case/File No.

1(d). Location (if different from mailing address)

1(e). Nature of Business

1(f). NYS U.I. Employer Reg. No.

2(a). Insurance Carrier

2(b). Carrier's Address

3(a). Injured Employee (First, M.I., Last)

3(b). Address

4(a). Address Where Accident Occurred

4(b). County

4(c). Was Accident on Employer's Premises?

5. Time of Accident

6. Dept. Where Regularly Employed

7(a). Date Stopped Work Because of This Injury/Illness

7(b). Was Employee Paid in Full for Day?

8. Sex

9(a). Age

9(b). Date of Birth

10. Occupation

11(a). Average Earnings Per Week?

11(b). Total Earnings Paid During 52 Weeks Prior to Date of Accident

12(a). Part or Full Time Employee?

12(b). Injured Employee's Work Week

13. Nature of Injury and Part(s) of Body Affected

14(a). Did You Provide Medical Care?

14(b). If Yes, When?

15(a). Name and Address of Doctor

15(b). Name and Address of Hospital

16(a). Has Employee Returned to Work?

16(b). If Yes, Give Date

16(c). At What Weekly Wage?

NOTE: FORM C-11 MUST BE FILED EACH TIME THERE IS A CHANGE IN EMPLOYMENT STATUS

17. What Was Employee Doing When Injured?

18. How Did the Accident or Exposure Occur?

19. Object or Substance That Directly Injured Employee

20(a). Date of Death

20(b). Name and Address of Nearest Relative

20(c). Relationship

Date Employer/Supervisor First Knew of Injury

Date of This Report

A. Employee Preparing Form or Supplying Information to Third Party

B. If Employee is Unable to Sign, Name of Person Completing Form

C. If Report Prepared by Third Party, Company Name and Address

D. Third Party Contact Name

Telephone Number & Extension

Employer/Supervisor Signature

Date

INSTRUCTIONS TO EMPLOYERS

Reports should be sent directly to the district offices at these addresses:

ALBANY 12241 - 100 Broadway, Menands. (518) 474-6674

BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (607) 721-8356

BUFFALO 14202 - Statler Towers, 107 Delaware Ave. (716) 842-2166

ROCHESTER 14614 - 130 Main Street West. (716) 238-8300

SYRACUSE 13203 - 935 James Street. (315) 423-2934

DOWNSTATE CENTRALIZED MAILING - PO Box 29017, Brooklyn, NY 11202-9017. NYC (718) 802-6600 Hemp. (516) 560-7700 Haup. (631) 952-6000 Peek. (914) 788-5775

WORKERS' COMPENSATION LAW

Section 13 Treatment and care of injured employees.

The employer shall promptly provide for an injured employee such medical, surgical, optometric or other attendance or treatment, nurse and hospital service, medicine, optometric services, crutches, eye-glasses, false teeth, artificial eyes, orthotics, functional assistive and adaptive devices and apparatus for such period as the nature of injury or the process of recovery may require.

Section 13 Injury to employee's prosthesis.

Damage to or loss of a prosthetic device shall be deemed an injury except that no disability benefits shall be payable with respect to such injury under section fifteen of this article.

Section 25 Effect of failure to file reports.

If the employer or its insurance carrier fails to file a notice or report requested or required by the board or chair or otherwise required within the specified time period or within ten days if no time period is specified, the board may impose a penalty in the amount of fifty dollars.

Section 51 Posting of notice regarding compensation.

Every employer who has complied with section fifty of this chapter shall post and maintain in a conspicuous place or places in and about his place or places of business typewritten or printed notices in form prescribed by the chairman, stating the fact that he has complied with all the rules and regulations of the chairman and the board and that he has secured the payment of compensation to his employees and their dependents in accordance with the provisions of this chapter, but failure to post such notice as herein provided shall not in any way affect the exclusiveness of the remedy provided for by section eleven of this chapter.

Section 52 Effect of failure to secure compensation.

Failure to secure the payment of compensation shall constitute a misdemeanor, punishable by a fine of not less than five hundred nor more than two thousand five hundred dollars or imprisonment for not more than one year, or both.

Where any person has previously been convicted of a failure to secure the payment of compensation within the preceding five years, upon conviction for a second violation such person shall be fined not less than one thousand nor more than five thousand dollars in addition to any other penalties including fines otherwise provided by law, and upon conviction for a third or subsequent violation such person may be fined up to seven thousand five hundred dollars in addition to any other penalties including fines otherwise provided by law.

Where the employer is a corporation, the president, secretary and treasurer thereof shall be liable for failure to secure the payment of compensation under this section.

Section 110 Record and report of injuries by employers.

An employer, or a third party designated by the employer, shall record any injury or illness incurred by one of its employees in the course of employment using the form prescribed by the chair for reporting injuries under subdivision two of this section. Such form, a copy of which shall be provided to the injured employee upon request, shall be maintained by the employer, or a third party designated by the employer, for at least eighteen years, and shall be subject to review by the chair at any time. Such form need not be filed with the chair unless the status of such injury or illness changes resulting in a loss of time from regular duties or in medical treatment which would require reporting in accordance with subdivision two of this section.

An employer, or a third party designated by the employer, shall file with the chair of the workers' compensation board and with the carrier if the employer is insured, upon a form prescribed by the chair, a report of any accident resulting in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid. Such report shall state the name and nature of the business of the employer, the location of its establishment or place of work, the name, address and occupation of the injured employee, the time, nature and cause of the injury and such other information as may be required by the chair. Such report shall be filed within ten days after the occurrence of the accident. An employer shall furnish a report of an occupational disease incurred by an employee in the course of his or her employment, to the chair of the workers' compensation board, and to the carrier if the employer is insured, upon the same form.

The carrier, within fourteen days of receipt of the report or accompanying the initial check forwarded to the employee, whichever is earlier, or a self-insured employer, within fourteen days of transmitting the report to the chair or accompanying the initial check forwarded to the employee, whichever is earlier, shall provide the injured employee or, in the case of death, his or her dependents with a written statement of their rights under this chapter, in a form prescribed by the chair. An employer shall file a report of any other accident resulting in personal injury incurred by its employee in the course of employment, upon the same form, whenever directed by the chair.

Any injury or illness which is not required to be reported in accordance with subdivision two of this section, shall not be used as a basis for determining experience modification rates, provided the employer pays in the first instance or reimburses the employer's insurer for the treatment rendered to the employee.

An employer who refuses or neglects to make a report or to keep records as required by this section shall be guilty of a misdemeanor, punishable by a fine of not more than one thousand dollars. The board or chair may impose a penalty of not more than two thousand five hundred dollars upon an employer who refuses or neglects to make such report.

The chair shall be authorized to promulgate regulations necessary to carry out the provisions of this section.

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

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What the Employer's First Report of Work Related Injury Form Is

Employer's First Report of Work Related Injury Form is a standardized employer-originated report used to notify the employer's workers' compensation insurer, the state workers' compensation agency, and internal HR or safety teams about a workplace injury or occupational illness. The form captures initial facts about the worker, the incident, preliminary medical treatment, and work status. Employers complete this report after learning of an injury that causes medical treatment beyond first aid, lost time, restricted duty, or death. Timely and accurate completion preserves claim records, supports regulatory reporting, and begins the insurer’s claims handling and medical management process.

Why timely and accurate first reports matter

Filing the Employer's First Report of Work Related Injury Form starts the official claim record, helps meet state reporting obligations, and enables prompt medical care coordination. Accurate early reporting reduces disputes, supports OSHA and workers' compensation compliance, and shortens claim resolution timelines.

Why timely and accurate first reports matter

Who prepares and relies on the first report

Typical users who prepare or receive the Employer's First Report include both internal and external stakeholders involved in workplace safety and claims.

  • HR and safety teams, document incident details, coordinate care, and maintain records for compliance.
  • Supervisors and managers, first-hand incident reporters responsible for prompt notification to HR or insurer.
  • Workers and claimants, provide symptom, treatment, and work-status information for the report.

Many third parties also review the report, including insurers, medical providers, and state agencies that oversee workers' compensation.

Step-by-step checklist for completing the form

Follow this sequential checklist to complete the Employer's First Report accurately and avoid processing delays.

  • 01
    Collect basic facts: Record employee name, SSN/TIN, job title, and contact details.
  • 02
    Describe the incident: Summarize what happened, where, when, and how.
  • 03
    Document treatment: Note first aid or medical care, provider, and dates.
  • 04
    Report work status: Indicate restrictions, light duty, or time off expected.

Key components to include on a professional first report

A complete Employer's First Report collects identity and employment data, incident facts, medical treatment, work status, initial witness statements, and insurer or agency routing details.

Worker identity

Full legal name, date of birth, Social Security number or TIN, mailing address, and employer-assigned ID if applicable to avoid identity mismatches.

Employment details

Job title, department, hire date, regular work schedule, and payroll/exposure classifications that affect benefits and loss coding.

Incident summary

Brief narrative of what occurred, exact location, tools or equipment involved, task being performed, and environmental conditions at the time.

Medical and provider data

Indicate type of treatment, provider name and address, dates of service, and whether further care or specialist referral was recommended.

Work status

State whether employee returned to regular duty, modified duty, or remains off work; include expected return-to-work date and any restrictions.

Routing information

List insurer, claim number if known, state agency filing requirements, and the internal contacts for HR, safety, and medical case management.

Required data elements for accurate records

Employee identifiers: Full name, SSN/TIN
Employment details: Job title, hire date
Incident specifics: Date, time, location
Treatment summary: First aid vs medical care
Work status: Return-to-work or off duty
Routing info: Insurer and state agency

Common mistakes to avoid when preparing the report

  • Incomplete or inconsistent identifiers such as misspelled names or incorrect SSNs delay insurer verification and may trigger backup withholding issues.
  • Omitting precise incident details or equipment involved forces repeated follow-up and slows causation and subrogation assessments.
  • Failing to record treatment dates or provider names can impede medical case management and prolong claim resolution.
  • Delaying submission beyond insurer or state timeframes increases the risk of penalties, benefit delays, and evidence degradation.

Risks and potential consequences of incorrect or late reports

Claim denial: Denial of benefits
Penalty fees: State fines possible
Delayed care: Slower medical treatment
Legal exposure: Increased litigation risk
OSHA citation: Recordkeeping violations
Audit risk: Examined by regulator

Where completed reports are typically sent

This section outlines typical routing for the completed Employer's First Report, including internal and external recipients and filing channels.

  • Send to insurer: Transmit to the workers' compensation carrier per policy or state deadline.
  • Notify state agency: File with the state workers' compensation board if required by law.
  • Provide to HR file: Keep a copy in the employee's personnel and medical files per retention rules.
  • Share with medical provider: Send treatment details and employer contact for follow-up care coordination.

How to configure an online first-report workflow

Configure an online template to map fields, apply validations, and set recipient routing for efficient electronic completion and recordkeeping.

Field Configuration
Auto-populate claimant contact and job fields Use HR data to prefill name, SSN, and job title.
Field validations and input formatting rules Require MM/DD/YYYY for dates and nine digits for SSN.
Conditional fields for treatment details Show medical provider fields only when medical treatment is indicated.
Automatic routing and notifications to stakeholders Email insurer and HR when form is submitted; log to safety system.

eSubmission and platform requirements

Confirm the eSignature platform and integrations before enabling online filing to ensure authentication, audit trail, and storage meet legal and employer requirements.

  • Identity verification: Use email, SMS, or KBA as required.
  • Audit trail: Capture IP, timestamp, and signer attribution.
  • Document formats: Accept PDF and DOCX; store read-only copies.

Typical timelines and reporting expectations

Reporting timelines vary by insurer and state; aim to file the Employer's First Report promptly to comply with policy and statutory deadlines.

Immediate internal notification to HR and safety:

Report incident to HR and supervisor within 24 hours of notice.

Insurer reporting deadline per policy:

Most carriers require notice within 7 to 30 days of injury.

State agency filing requirement varies:

Some states require electronic or paper first reports within specific deadlines.

OSHA recordability and reporting:

If injury meets recordable criteria, update OSHA logs and Form 300/301 as required.

Medical follow-up and reporting:

Provide treating provider info and schedule follow-up to document recovery and work capacity.

Typical eSignature vendor pricing and capability snapshot

Compare common vendor pricing and features when selecting an eSignature solution for first-report workflows; signNow appears first for straightforward plan and capability reference.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Real-world examples of streamlined first-report workflows

The examples below illustrate how electronic first report workflows reduce delays and improve record accuracy across common employer settings.

Case Study 1

A mid-sized construction employer switched to an electronic Employer's First Report workflow after repeated delays from paper reports, improving submission speed and documentation completeness.

  • Submission time dropped dramatically.
  • The employer routed completed reports directly to insurer and safety teams, attached site photos and witness statements, and reduced follow-up inquiries. Accurate incident details shortened investigations and improved return-to-work planning.

Case Study 2

A community healthcare clinic used electronic first reports to combine HIPAA-compliant medical details with employer reporting, maintaining privacy while meeting insurer and state obligations.

  • Medical and employer records aligned.
  • Using role-based access controls and a signed BAA with the eSignature vendor, the clinic provided necessary treatment data to insurers without exposing unnecessary PHI, streamlining claim triage and protecting patient privacy.

Who typically signs or authorizes the report

HR Manager

The HR manager or authorized employer representative completes and signs the Employer's First Report, coordinates medical information collection, and maintains personnel records. They verify identifiers, document work restrictions, and communicate with the insurer and safety team during claim intake and follow-up.

Claims Adjuster

The insurer's claims adjuster receives the report, opens the claim file, requests additional documentation, and manages medical case administration. The adjuster determines compensability, assigns loss codes, and tracks payments and reserves based on the initial report.

FAQs and troubleshooting for common questions

Answers to frequent operational and legal questions about preparing, signing, and storing the Employer's First Report of Work Related Injury Form.


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