New York
Workers Compensation
200 Ratings
Last updated: 4/13/2023
Employers Statement Of Wage Earnings (Preceding Date Of Injury-Illness) {C-240}
Start Your Free Trial $ 14.00What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
null
Related forms
-
Application For Acceptance Of Insurance Form
New York/Workers Compensation/ -
Carriers Report On Rehabilitation To Chair Workers Compensation Board
New York/Workers Compensation/ -
Claim For Compensation In Death Case
New York/Workers Compensation/ -
Claimants Authorization To Disclose Workers Compensation Records
New York/Workers Compensation/ -
Notice Of Election Provide WC To Participants In Sheltered Workshop
New York/Workers Compensation/ -
Notice To Liable Political Subdivision Of Volunteer Firefighters Injury Or Death
New York/Workers Compensation/ -
Statement Of Unresolved Issues-Special Part For Expedited Hearings
New York/Workers Compensation/ -
Stipulation
New York/Workers Compensation/ -
Carriers Request For Reimbursement Of Compensation Payments Under Section 14(6) (Blue Paper)
New York/Workers Compensation/ -
Claim For Volunteer Ambulance Workers Benefits In A Death Case
New York/Workers Compensation/ -
Claim For Volunteer Firefighters Benefits In A Death Case
New York/Workers Compensation/ -
Electronic Attachment
New York/Workers Compensation/ -
Proof Of Death By Physician Last In Attendance On Deceased
New York/Workers Compensation/ -
ADR Program Final Disposition Of Claim
New York/Workers Compensation/ -
Record Of Percentage Hearing Loss
New York/Workers Compensation/ -
Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper)
New York/Workers Compensation/ -
Notice Of Election To Bring Partners Or Self Employed Under NY WC
New York/Workers Compensation/ -
Notice Of Right To Select Workers Compensation Board Authorized Health Care Provider
New York/Workers Compensation/ -
Claimants Authorization To Disclose Workers Compensation Records (Autorizacion Del Reclamante - Spanish)
New York/Workers Compensation/ -
Notice Of Right To Reimbursement Of Compensation Payments
New York/Workers Compensation/ -
Disability Benefits Law Employer Identification Information
New York/Workers Compensation/ -
Health Insurers Request For Reimbursement
New York/Workers Compensation/ -
Notice Of Election Corporation Exclude Sole Shareholder Officers Shareholders From WC
New York/Workers Compensation/ -
Notice Of Election Municipal Corporation Other Political Subdivision Bring Executives Under NY WC
New York/Workers Compensation/ -
Notice Of Election Nonprofit To Exclude Unsalaried Executive Officer From WC
New York/Workers Compensation/ -
Notice Of Retainer And Appearance On Behalf Of Employer
New York/Workers Compensation/ -
Revocation Of Election Corporation Exclude Sole Shareholder Officer From WC Coverage
New York/Workers Compensation/ -
Revocation Of Election Municipal Corporation Other Political Subdivision Bring Executives Under NY WC
New York/Workers Compensation/ -
Revocation Of Election Nonprofit Or Unincorporated Assoc To Exclude Unsalaried Officer From WC
New York/Workers Compensation/ -
Cover Sheet-List Of Itemized Medical Bills In Controverted World Trade Center Case
New York/Workers Compensation/ -
Licensed Representatives Disclosure Of Conflict Of Interest To Client
New York/Workers Compensation/ -
Notice Of Election Of Corporation To Exclude Shareholder Officers From Disability Coverage
New York/Workers Compensation/ -
Modification Of Previous Report (ADR Program)
New York/Workers Compensation/ -
Self Insurers Representatives Bond
New York/Workers Compensation/ -
Request For Judicial Order - Access To Case Files
New York/Workers Compensation/ -
Claimants Record Of Job Search Efforts Contacts
New York/Workers Compensation/ -
Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only)
New York/Workers Compensation/ -
Loss Of Wage Earning Capacity Vocational Data Form
New York/Workers Compensation/ -
Notice That Claimant Must Arrange For Diagnostic Tests And Examinations Through Network Provider
New York/Workers Compensation/ -
Initial Application To Take License Rep Exam To Appear On Behalf Of Claimants Or To Represent Carriers-Self-Insurers
New York/Workers Compensation/ -
Attorney-Representatives Certification Of Form C-3 Or Notice Of Controversy
New York/Workers Compensation/ -
Independent Examiners Report Of Request For Information Or Response To Request Regarding Ind Med Exam
New York/Workers Compensation/ -
Paid Family Leave Supplement To Certificate Of Insurance
New York/Workers Compensation/ -
Employer Whistleblower Form
New York/Workers Compensation/ -
Attachment For Report Of Ind Med Exam Non Scheduled Perm Partial Disability
New York/Workers Compensation/ -
Attachment For Report Of Independent Med Exam Scheduled Loss Of Use
New York/Workers Compensation/ -
Claimants Record Of Independent Job Search Efforts
New York/7 Workers Compensation/ -
Claimants Statement Regarding No Fault Or Personal Injury
New York/7 Workers Compensation/ -
Report Of Impartial Specialist Examination Or Record Review
New York/7 Workers Compensation/ -
Application For License To Represent Insurers And Or Self-Insurers
New York/Workers Compensation/ -
Independent Examiners Report of Independent Medical Examination
New York/Workers Compensation/ -
Waiver Agreement - Section 32 WCL
New York/Workers Compensation/ -
Direct Deposit Authorization Form
New York/7 Workers Compensation/ -
Extreme Hardship Redetermination Request
New York/7 Workers Compensation/ -
Practitioners Report Of Functional Capacity Evaluation
New York/Workers Compensation/ -
Claimants Record Of Medical And Travel Expenses And Request For Reimbursement
New York/7 Workers Compensation/ -
Carriers Request Benefit Increase Reimbursement Under VF-VAW Benefit Laws
New York/7 Workers Compensation/ -
Sexual Harassment Policy
New York/7 Workers Compensation/ -
Sexual Harassment Prevention Poster
New York/7 Workers Compensation/ -
Insurers Notification Of Initial Request For Reimbursement 14(6) Or 15(8)
New York/7 Workers Compensation/ -
Limited Release Of Health Information (HIPAA)
New York/Workers Compensation/ -
Application For Reopening Of Claim More Than Seven Years After Accident
New York/Workers Compensation/ -
Report Of Work-Related Injury Or Occupational Disease
New York/Workers Compensation/ -
Volunteers Notification Of Exec Officer Fire-Ambulance Company-Significant Risk Of HIV
New York/Workers Compensation/ -
Notice Of Insurers Refusal To Pay Medical Bill Valuation Objections
New York/7 Workers Compensation/ -
Notice Of Objection To Payment Of Bill For Treatment Provided
New York/Workers Compensation/ -
Employee Claim
New York/Workers Compensation/ -
World Trade Center Volunteers Claim For Compensation
New York/Workers Compensation/ -
Request For Further Action By Legal Counsel
New York/Workers Compensation/ -
Application For A Fee By Claimants Attorney Or Representative
New York/Workers Compensation/ -
Notice Of Retainer And Appearance Or Notice Of Substitution And Appearance
New York/Workers Compensation/ -
Notice That You May Be Responsible For Medical Costs
New York/Workers Compensation/ -
Doctors Report Of MMI-Permanent Impairment
New York/Workers Compensation/ -
Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement
New York/Workers Compensation/ -
Section 32 Electronic Signature
New York/Workers Compensation/ -
Medical Proof Of Change Re Application For Reopening Claim
New York/Workers Compensation/ -
Claimants Notice Of Independent Medical Examination
New York/Workers Compensation/ -
Physicians Application For Designation As Impartial Specialist
New York/7 Workers Compensation/ -
Physicians Application For Renewal Of Designation As Impartial Specialist
New York/7 Workers Compensation/ -
Notice To Chair Of Withdrawal Of Request For Arbitration
New York/Workers Compensation/ -
Notice Of Election To Voluntarily Exclude Spouse From Coverage
New York/Workers Compensation/ -
Supplement To Certificate Of Insurance
New York/Workers Compensation/ -
Employers Statement Of Wage Earnings (Preceding Date Of Injury-Illness)
New York/7 Workers Compensation/ -
Impartial Specialists Report Of Medical Records Review
New York/Workers Compensation/ -
Employers Application Voluntary For Employees Benefits Not Required (No Contrib)
New York/Workers Compensation/ -
Employers Application Voluntary For Employees Benefits Not Required (Employee Contrib)
New York/Workers Compensation/ -
Employers Statement For Purpose Of Terminating Status As Covered Employer
New York/Workers Compensation/ -
Claim For Compensation And Notice Of Commencement Of Third Party Action
New York/Workers Compensation/ -
World Trade Center September 11th Victim Compensation Fund Authorization
New York/7 Workers Compensation/ -
World Trade Center Volunteer HIPAA Authorization
New York/7 Workers Compensation/ -
Biannual Recertification To Entitlement To Benefits
New York/Workers Compensation/ -
Pre Hearing Conference Statement
New York/Workers Compensation/ -
Notice To Liable Political Subdivision Or Unaffiliated Ambulance Service
New York/Workers Compensation/ -
Occupational Injury-Illness Statement Of Rights
New York/7 Workers Compensation/ -
Attorney-Licensed Representative Request To Withdraw From Representation
New York/Workers Compensation/ -
Notice Of Election Religious Charitable Organization Bring Executives Under NY WC
New York/Workers Compensation/ -
Revocation Of Election Religious Charitable Organization Bring Executives Under NY WC
New York/Workers Compensation/ -
Volunteer Firefighters Claim For Benefits
New York/Workers Compensation/ -
Volunteer Ambulance Workers Claim For Benefits
New York/Workers Compensation/ -
Employers Report Of Injured Employees Change In Employment Status Resulting From Injury
New York/Workers Compensation/ -
Request For Assistance By Injured Worker
New York/Workers Compensation/ -
Request For Further Action By Insurer-Employer
New York/Workers Compensation/ -
Employers Application To Have Association Union Or Trustee Plan Accepted As Employers Plan
New York/Workers Compensation/ -
Statement Of Registration Section 13n-WCL IME Entity
New York/Workers Compensation/ -
Application For Plan Of Employer - Disability And-Or Family Leave
New York/7 Workers Compensation/ -
Employees Statement Of Exempt Status
New York/Workers Compensation/ -
Registration Of Participation In WTC Rescue Recovery Clean-Up Operations
New York/Workers Compensation/ -
Notice And Proof Of Claim For Disability Benefits
New York/Workers Compensation/ -
Providers Request For Judgment Of Award
New York/Workers Compensation/ -
Carriers Or Self-Insured Employers Affirmation
New York/7 Workers Compensation/ -
Affirmation For Death Benefits
New York/Workers Compensation/ -
Consent To NYS WCB Jurisdiction For Non-NY Carriers (3C Coverage)
New York/Workers Compensation/ -
Insurers Request For Reconsideration Of Reduction Under WCL § 14(6) Or 15(8)
New York/7 Workers Compensation/ -
Insurers Request For Reimbursement Of Medical Payments WCL Section 15(8)
New York/7 Workers Compensation/ -
Proof Of Burial And Funeral Expenses By Undertaker
New York/Workers Compensation/ -
Renewal Application For License To Appear On Behalf Of Claimant
New York/Workers Compensation/ -
Section 32 Waiver Agreement Claimant Release
New York/Workers Compensation/ -
Employers First Report Of Work-Related Injury Or Illness
New York/Workers Compensation/ -
Discharge Or Discrimination Complaint
New York/Workers Compensation/ -
Affirmation For License To Operate An X-Ray Bureau Or Laboratory
New York/Workers Compensation/ -
Application For Self-Insurance (Disability And Paid Family Leave Benefits)
New York/Workers Compensation/ -
Application For Approval Plan Of Association - Disability Family Leave Benefits
New York/7 Workers Compensation/ -
Application For Board Review
New York/Workers Compensation/ -
Rebuttal Of Application For Board Review
New York/Workers Compensation/ -
Application For Reconsideration Full Board Review
New York/Workers Compensation/ -
Rebuttal Of Application For Reconsideration Full Board Review
New York/Workers Compensation/ -
Unemployment – Record of Employment
New York/7 Workers Compensation/ -
Reclamacion Del Empleado
New York/Workers Compensation/
Form Preview
Sorry, we couldn't download the pdf file.
Our Products
Contact Us
Success: Your message was sent.
Thank you!