Transcription of EMPLOYER'S REPORT OF WORK-RELATED INJURY/ILLNESS C-2
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EMPLOYER'S REPORT OF WORK-RELATED INJURY/ILLNESS C-2
FemaleEMPLOYER'S REPORT OF WORK-RELATED INJURY/ILLNESSS tate of New York - Workers' Compensation BoardC-2C. EMPLOYEE'S PERSONAL INFORMATION1. Name:3. Mailing Address:4. Social Security Number:Male6. Gender:WCB Case Number (if you know it):If one of your employees has a WORK-RELATED injury or illness, you must complete and file this formwithin 10 daysof theinjury/illness or be subject to a additional information on filing this form please refer to Workers'Compensation Law Section 110 at the end of this form. Type or print EMPLOYER INFORMATION1. Employer:2. Employer FEIN:3. Mailing Address:4. Location Address (if different):6.
If yes, name the doctor(s) who treated the previous injuries/illnesses (if known): 3. Is the employee still being treated for this injury/illness? 4. To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while working for you? Yes No Yes No F. RETURN TO WORK 1.
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