NF-6: New York Employer's Wage Verification Report

NF-6 PDF Details

Please complete and submit this form to the claims representative as soon as possible.

Employment: employee's occupation; dates of employment; gross earnings during 52 week period prior to accident.

Benefits: Has employee received, is employee receiving or is employee entitled to receive benefits under any workers' compensation law as a result of this accident?

Disability: Has employee received, is employee receiving or is employee entitled to receive New York State disability benefits as a result of this accident?

Absence: Was or will employee be paid by employer for this absence from work? If answer to question 7 is "YES" please answer questions 8, 9, 10 and 11.