Please select a workers' compensation form below:

• Insurance Certificate Request
  
  
• Loss Run Request
  
  
• C-105 Posting Notice Request
  
  
• First Aid Report
  
  

The Packet consists of 10 separate New York State workers' compensation forms. You may view and print them as a single, 18-page document by clicking here, or open them one at a time by clicking on the individual links below.

Employee Information Packet

• Cover Letter and Instructions.pdf
  
  
• Receipt for Employee Information Packet.pdf Field-fillable pdf.
  
  

New C-2 Forms Documents

The new C2 Form (and other forms that require information to be filled in) is available below as a field-fillable pdf file. Instructions for completing field-fillable forms.

• C-2 Form ("Employer's Report of Work-Related Injury/Illness") Field-fillable pdf.
  
  
• Instructions for Completing Form C-2 ("Employer's Report of Work-Related Injury/Illness"). pdf.
  
  

New C-3 Form and C-3.3 Documents

• C-3 Form ("Employee Claim"). Field-fillable pdf. 2 pages.
  
  
• Instructions for Completing Form C-3 ("Employee Claim"). pdf.
  
  
• C-3.3 Form ("Limited Release of Health Information"). Field-fillable pdf. Spanish/English.
  
  

Related Documents

• Statement of Rights. Spanish/English. pdf.
  
  
• HIPAA Release. Field-fillable pdf.
  
  
• Prescription Drug Form. Field-fillable pdf.
  
  

Instructions for completing field-fillable forms.

The field-fillable forms above can be completed in one of two ways:

• Fill out the form from your computer, and then print it out, and sign where indicated; or
• Print out the form and then fill it out by hand and sign.

Forms can then be delivered by fax, mail, or in person to NCAComp or to the appropriate location.

Detailed instructions for filling out field-fillable pdfs.