Please rate Form C 3 6-22
Failure to file within two years after the date of injury may result in your claim being denied.
Where to send: Send it to the Workers' Compensation Board centralized mailing address listed at the end of these instructions.
Signer: An individual may sign on behalf of the employee only if they are legally authorized and the employee is a minor, mentally incompetent or incapacitated.
Social security number: Providing your social security number to the Board is voluntary.
Translator: Board hearings are conducted in English. If you need a translator, select Yes and indicate the language needed.
Form C-3.3: If you already had an injury to the same body part or a similar illness and were treated by a doctor, complete and file Form C-3.3 together with this form.
| Question | Answer |
|---|---|
| Form Name | Form C-3 |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 162 |
| Avg. time to fill out | 27 min |
| Edition | 6-22 |
| Issuing agency | State of New York Workers' Compensation Board |
| Filing deadline | Two years after the date of injury |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | C-3, C3, C 3, Form C-3, Employee Claim, NY C-3, New York C-3, C-3 Employee Claim |
| Official source | Form C-3 (Rev 6-22), New York State Workers' Compensation Board |
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Please rate Form C 3 6-22
