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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.

If available, attach a copy of the employee's written notice and medical notes, and the employer's incident report. C-2.0 (9-08) Page 1 of 3 www.wcb.state.ny.us other vehicle

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