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Employee Claim C-3

Employee Claim State of New York - Workers' Compensation Board THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATIONC-3 Number and Street City State Zip CodeB. YOUR EMPLOYER(S)1. Employer when injured:3. Your work address:6. List names/addresses of any other employer(s) at the time of your injury/illness:7. Did you lose time from work at the other employment(s) as a result of your injury/illness?NoYesFemaleA. YOUR INFORMATION ( Employee )1.

representative, the Advocate for Injured Workers at the Workers' Compensation Board can help you. Call: 800-580-6665. To Health Care Provider: copy of this HIPAA-compliant release allows you to disclose health information. If you send records to theA

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INJURED ON THE JOB? - New York State Workers' …

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The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to …

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