Your employer is the company or agency that issues your paycheck.
Case number: if you do not have or know your Workers' Compensation Board Case Number, please leave this field blank. It is not required to process your claim.
Help: if you need additional help completing this form, contact the Workers' Compensation Board at 1-877-632-4996.
Page two: remember to enter your name and the date of your injury/ illness on the top of page two.
Doctor bills: DO NOT pay your doctor or hospital. Their bills will be paid by the insurance carrier if your case is not disputed.
Two years: failure to file within two years after the date of injury may result in your claim being denied.
| Question | Answer |
|---|---|
| Form Name | 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 |
| Where to send | New York State Workers' Compensation Board Centralized Mailing PO Box 5205 Binghamton, NY 13902-5205 |
| Other names | C-3, C-3.0, C3, WCB C-3, Form C-3, Employee Claim, NY WCB C-3 |
| Official source | C-3 (Rev 6-22), State of New York, Workers' Compensation Board |
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