Wcb Form Ec 3 – Fill Out and Use This PDF

Employee Claim

EC-3

State of New York - Workers' Compensation Board

THIS FORM IS BEING SUBMITTED ELECTRONICALLY. DO NOT MAIL TO THE BOARD.

Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness.

*Required Fields

Select

for additional information

WCB Case Number (if you know it):

A. YOUR INFORMATION (Employee)

1.

*First Name:

*Last Name:

MI:

2.

*Mailing address:

Line 2:

*City:

State:

Zip Code:

*Country:

3.

*Date of Birth:

4. Social Security Number:

5.

*Phone Number:

6. *Gender:

Male

Female

7.

*Will you need a translator if you have to attend a Board hearing?

Yes

No

B. YOUR EMPLOYER(S)

1. *Employer when injured:

2.

*Your work address:

Line 2:

*City:

State:

Zip Code:

*Country:

3. Phone Number:

4. Date you were hired:

5.

Your supervisor's first name:

Last name:

6. Did you have more than one employer at the time of your injury/illness?

Yes

No

C. YOUR JOB on the date of the injury or illness

1.*What was your job title or description?

2.What types of activities did you normally perform at work?

3.*Was your job? (check one) Full Time Part Time Seasonal Volunteer Other:

4.*What was your gross pay (before taxes) per pay period?

5.*How often were you paid?

6.*Did you receive lodging or tips in addition to your pay? Yes No

D. YOUR INJURY OR ILLNESS

1. *Date of injury or date of onset of illness:

2. Time of injury:

AM

PM

3.*Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)

4.*Was this your usual work location? Yes No

5.*What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report)

6.*How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)

7.*Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):

8.*Was an object (e.g., forklift, hammer, acid) involved in the injury/illness? Yes No

9.*Was the injury the result of the use or operation of a licensed motor vehicle? Yes No

10.*Have you given your employer (or supervisor) notice of injury/illness? Yes No

11.*Did anyone see your injury happen? Yes No Unknown

E. RETURN TO WORK

1. *Did you stop work because of your injury/illness? Yes No

F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS

1.*Did you receive treatment for your injury or illness? Yes None received

2.*Do you remember having another injury to the same body part or a similar illness? Yes No

Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.

Please Note: If you have retained a legal representative at the time of filling out this on-line EC-3, then you must notify your legal representative that they must complete and sign form OC-400.5 (Attorney/Representative's Certification of form C-3 or C-7) and mail it to the Board.

An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.

*Prepared By:		Employee		On Behalf of Employee
*First Name:					*Last Name:		MI:
Date:

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