C 11 Form PDF Details

In the realm of workplace injuries, communication and proper documentation are crucial for both employers and employees to navigate the complexities of workers' compensation claims effectively. The Employer's Report of Injured Employee's Change in Employment Status, more commonly known as the C-11 form, serves as a vital tool in this process. Located in Binghamton, NY, with options for fax, web upload, and email filing, this report facilitates the timely update of significant changes in an injured employee's work status directly to the Workers' Compensation Board. It addresses various adjustments including the return to work, discontinuation of work, modifications in work hours, and alterations in wages, which can arise following an injury. Employers must promptly file this report following any change from the status previously reported on the initial Injury Report or a preceding C-11 or EC-11 form. Additionally, sending a copy to the insurer is also required. Critical to this process is the accurate and honest representation of the injured employee’s circumstances, as falsification of this information is a criminal offense. Through this reporting mechanism, the Workers' Compensation Board aims to ensure that employees with disabilities, among others, are treated without discrimination and receive the compensation and support they are entitled to during their recovery.

QuestionAnswer
Form NameC 11 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesc 11, ny c11, new york c11, ny c11 form

Form Preview Example

EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE

C-11

IN EMPLOYMENT STATUS RESULTING FROM INJURY

PO Box 5205, Binghamton, NY 13902-5205

Fax #: (877)-533-0337 l Web Upload Link: https://wcbdoc.xrxfs.com/login.aspx l Email Filing: wcbclaimsfiling@wcb.ny.gov

This report is to be filed directly with the Chair, Workers' Compensation Board as soon as the employment status of an injured employee, as reported on First Report of Injury, or on a previous Form C-11 or EC-11, is changed. Change in employment status includes return to work, discontinuance of work, increase or decrease of regular hours of work and increase or reduction of wages. A copy should also be sent to your insurer.

Claim Information - ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS

Date of Injury/Illness:

 

WCB Case #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Administrator Claim (Carrier Case) #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

 

 

 

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

 

MI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

 

Line 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

 

 

 

 

Zip Code:

Country:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone #:

 

 

 

 

 

 

 

 

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security #:

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

Male

Female

 

 

 

 

 

 

 

 

 

Employer Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

 

Line 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

 

 

 

 

Zip Code:

Country:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Phone #:

 

 

 

 

 

Federal Tax ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

The Tax ID # is the (check one):

SSN

EIN

 

 

Insurer Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurer ID (W#):

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Line 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

 

 

 

 

Zip Code:

 

Country:

 

 

 

 

 

 

 

 

 

 

 

Insurer Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of first full day employee lost from work:

 

 

 

 

 

 

 

 

Date employee first returned to work:

 

 

 

 

 

 

 

 

 

 

Loss of time resulting from the above injury since initial date of lost time or last C-11 filed with the Board:

Loss of Time

Start Date

Return To Work Date

Reason

As a result of the above injury, was there an increase or decrease in hours worked or wages paid? Yes No If yes, enter status of change below:

Employment Status

Effective Date

Hours per Day

Days per

Earnings

Remarks

Week

 

 

 

 

 

 

 

 

 

 

 

Prior to Injury

 

 

 

 

 

 

 

 

 

 

 

Changed To

 

 

 

 

 

 

 

 

 

 

 

An employer or insurer, or any employee, agent, or person acting on behalf of an employer or insurer, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

Prepared By:

Last Name:

 

 

 

 

First Name:

 

 

MI:

Employer Name:

 

 

 

 

 

 

 

 

 

 

Official Title:

 

 

 

 

Phone #:

 

 

 

Email Address:

 

 

 

Date of this report:

 

 

 

 

C-11 (6-17)

www.wcb.ny.gov

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES

 

 

 

 

 

 

PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

 

 

How to Edit C 11 Form Online for Free

Filling in the c 11 form nys form is easy using our PDF editor. Follow these steps to create the document right away.

Step 1: Select the button "Get Form Here" on this webpage and next, click it.

Step 2: Once you access the c 11 form nys editing page, you'll see lots of the options it is possible to undertake with regards to your form in the top menu.

For each section, complete the content requested by the application.

portion of blanks in c 11 form fillable

Write down the necessary data in Insurer Information, Insurer Name, Mailing Address, City, Insurer Phone, Line, State, Zip Code, Country, Insurer ID W, Date of first full day employee, Date employee first returned to, Loss of time resulting from the, Loss of Time Start Date, and Return To Work Date box.

step 2 to completing c 11 form fillable

Describe the significant particulars in the Employer Name, Official Title, Email Address, Phone, Date of this report, wwwwcbnygov, and THE WORKERS COMPENSATION BOARD part.

c 11 form fillable Employer Name, Official Title, Email Address, Phone, Date of this report, wwwwcbnygov, and THE WORKERS COMPENSATION BOARD blanks to complete

Step 3: Hit the Done button to save the form. Now it is accessible for upload to your electronic device.

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