Fill and Sign the Employers First Report of Work Related Injuryillness Form C

WORKERS' COMPENSATION BOARD STATE OF NEW YORK - 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 afteran accident occurs. ANSWER ALL QUESTIONS FULLY. A copy should also be provided to or retained by your workers' compensationinsurance carrier. Any employer who fails to timely file Form C-2, as required by Section 1 10 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 I (b) COUNTY 4. (a) ADDRESS WHERE ACCIDENT OCCURRED (c)WAS ACCIDENT ON EMPLOYER'S A C C I D E N T PREMISES? Yes No 5. TIME OF ACCIDENT 6. DEPT. WHERE REGULARLY EMPLOYED (b) WAS EMPLOYEE PAID IN FULL 7.(a) DATE STOPPED WORK BECAUSE OF THIS INJURY/ILLNESS FOR DAY? Yes No 8. SEX 9.(a) AGE (b) DATE OF BIRTH 10. OCCUPATION (Specific job title at which employed) mo~ DAY YEAR N PJ EU RR SE 0D N N A T U R E 13. NATURE OF INJURY AND PART(S) OF BODY AFFECTED 14. (a) DID YOU PROVIDE MEDICAL CARE? (b) IF YES, WHEN? Yes No 15. (a) NAME AND ADDRESS OF DOCTOR (b) NAME AND ADDRESS OF HOSPITAL 0 F I N i u Ry 16. (a) HAS EMPLOYEE RETURNED TO WORK? (b) IF YES, GIVE DATE (c) AT WHAT WEEKLY WAGE? Yes No NOTE: FORM C-11 MUST BE FILED EACH TIME THERE IS A CHANGE IN EMPLOYMENT STATUS 17. WHAT WAS EMPLOYEE DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material the employee was using.) c A u s E 0 F 18. HOW DID THE ACCIDENT OR EXPOSURE OCCUR? (Please describe fully the events that resulted in injury or occupational disease. Tell what happened and how it happened. Please useseparate sheet if necessary.) A c c I D E N T 19. OBJECTOR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE. e.g. the machine employee struck against or which struck him/her, the vapor or poison inhaled or swallowed, the chemicalthat irritated his/her skin. In cases of strains, the thing (s)he was lifting, pulling, etc. 20. (a) DATE OF DEATH (b) NAME AND ADDRESS OF NEAREST RELATIVE (c) RELATIONSHIP FATALCASES DATE OF THIS REPORT DATE EMPLOYER/SUPERVISOR FIRST KNEW OF INJURY F FORM S SUBM TTFD BY FMP1 OYFP COMPI FTF A S. B BF1 OVVF FORM S SUBM TTFD BY TH RD PARTY COMPI FTF A B 0 S. D BF1 OVV p R E p A R AT I 0 N C-2 (8-00) C-2 C-2 C-2 C-2 C-2 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 (b) EMPLOYER'S MAILING ADDRESS (c) OSHA CASE/FILE NO. (d) LOCATION (if Different From Mailing Address) (e) NATURE OF BUSINESS (Principal Products, Services, etc.) (f) NYS U.I. EMPLOYER REG. NO. 2.(a) INSURANCE CARRIER (b) CARRIER'S ADDRESS 3.(a) INJURED EMPLOYEE (First, M.I. Last) (b) ADDRESS (includes No. & Street, City, State, Zip & Apt. No.) AM PM 1 1. (a) AVERAGE EARNINGS PER WEEK? (b) TOTAL EARNINGS PAID DURING 52 WEEKS PRIOR TO DATE OF ACCIDENT (include bonuses, overtime, value of lodging, etc.) 12. (a) PART OR FULL TIME EMPLOYEE? (b) INJURED EMPLOYEE'S WORK WEEK (indicate days of week usually worked.) IL LP~ONLN,MBLR&LAILNSION B.111 L A. EMPLOYEE PREPARING FORM OR SUPPLYING INFORMATION TO THIRD PARTY C. IF REPORT PREPARED BY THIRD PARTY, COMPANY NAME AND ADDRESS TELEPHONE NUMBER & EXTENSION D. THIRD PARTY CONTACT NAME INSTRUCTIONS TO EMPLOYERS: reports should be sent directly to the district offices at these addresses: ALBANY 12241 - 100 Broadway, Menands. (518) 474-6674 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Orange, , Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (607) 721-8356 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14202 - Statler Towers, 107 Delaware Ave. (716) 842-2166 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (716) 238-8300 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (315) 423-2934 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 29017, Brooklyn, NY 11202-9017. NYC (718) 802-6600 Hemp. (516) 560-7700 Haup. (631) 952-6000 Peek. (914) 788-5775 For all accidents in the following counties: Bronx, Kings, Nassau, New York, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. WORKERS' COMPENSATION LAW Section 13 Treatment and care of injured employees. (a) ''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 mayrequire.'" Section 13 Injury to employee's prosthesis. (a) ''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. ****-I Section 25 Effect of failure to file reports. 3. (e) ''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. ****-I 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 shallnot 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. 1. (a) ''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. (b) 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 thousanddollars in addition to any other penalties including fines otherwise provided by law, and upon conviction for a third or subsequentviolation such person may be fined up to seven thousand five hundred dollars in addition to any other penalties including fines otherwiseprovided by law. (c) 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. ****-I Section110 Record and report of injuries by employers. 1. 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, acopy of which shall be provided to the injured employee upon request, shall be maintained by the employer, or a third party designatedby 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 thechair unless the status of such injury or illness changes resulting in a loss of time from regular duties or in medical treatment whichwould require reporting in accordance with subdivision two of this section. 2. 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 requiredby the chair. Such report shall be filed within ten days after the occurrence of the accident. An employer shall furnish a report of anoccupational 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 oraccompanying the initial check forwarded to the employee, whichever is earlier, or a self-insured employer, within fourteen days oftransmitting the report to the chair or accompanying the initial check forwarded to the employee, whichever is earlier, shall provide theinjured employee or, in the case of death, his or her dependents with a written statement of their rights under this chapter, in a formprescribed by the chair. An employer shall file a report of any other accident resulting in personal injury incurred by its employee in thecourse of employment, upon the same form, whenever directed by the chair. 3. 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'sinsurer for the treatment rendered to the employee. 4. 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 thantwo thousand five hundred dollars upon an employer who refuses or neglects to make such report. 5. 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 C-2 (8-00) Reverse