C 240 Form – Fill Out and Use This PDF

C 240 Form PDF Details

The C-240 form, officially titled “Employer’s Statement of Wage Earnings (Preceding the Date of Injury/Illness),” is a required document in New York’s workers’ compensation system. The New York Workers’ Compensation Board (WCB) uses the data submitted on this form to calculate an injured worker’s average weekly wage, which directly determines the benefit rate for the claim.

Who Must Complete the C-240 Form

Employers are required to complete and submit this form when a workers’ compensation claim is filed for an injured employee. The document must be returned to the WCB within 10 days of receiving the request. It covers the injured worker’s payroll data for up to 52 weeks immediately before the date of injury or illness. In some situations, the employer must also report the earnings of an employee of the same class working the same number of days per week, so the board can establish a fair average weekly wage.

Key Information Required on the Form

The form asks for the injured worker’s name, WCB case number, date of injury or illness, and week-by-week payroll information. For each week, employers record the week ending date, days worked, and the gross amount paid, including any additional forms of compensation. Tips, board, rent, lodging, housing, and gratuities all count as earnings and must be reported. If the injured worker did not complete a full year of employment due to military service, layoffs, or other circumstances, separate sections of the form allow employers to account for these variables and still arrive at an accurate wage figure.

Legal Obligations and Penalties

Completing this form accurately is a legal obligation under New York workers’ compensation law. Employers who knowingly provide false or misleading information face serious penalties. Once submitted, the form becomes part of the official claim record and may be reviewed by claims examiners, legal representatives, and WCB staff. Maintaining complete payroll records throughout the year makes this process straightforward when a claim arises. The WCB calculates average weekly wage by dividing total annual earnings by the number of weeks worked during that year, so every week of payroll data matters.