you were injured at work. what now? · a worker’s responsibilities you must tell your employer,...
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THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
STATE OF NEW YORK WORKERS’ COMPENSATION BOARD
100 BROADWAY-MENANDS ALBANY, NY 12241
(877) 632-4996
You were injured at work. What now? The New York State Workers’ Compensation Board has received notice you suffered a workplace injury or illness, so we’re preparing a workers’ compensation case in your name. You may have already received medical treatment. If you haven’t, you should seek medical care as soon as possible.
A Worker’s Responsibilities You must tell your employer, in writing, when, where and how you were injured.
Do this within 30 days of injury. Medical reports are necessary for your case. Advise your doctors that you have a work-
related injury, and give the name of your employer. Do not pay for your care yourself or use other health insurance. Tell your doctor to file reports with the Board and with your employer or its insurance carrier. If your case is disputed, the Board needs a medical report on your injury to begin resolving your claim.
Starting a Case Once your employer knows of your injury, it must notify this Board by filing a C-2 form. You should file an employee claim (C-3 form) reporting your injury as soon as possible. (You must notify the Board of your injury or illness within two years.) If you injured the same body part before, or had a similar illness, you must also file a Form C-3.3. If you haven’t already filed a C-3 or C-3.3 (if necessary), there are three ways to do it. Visit www.wcb.state.ny.us/content/main/onthejob/howto.jsp to complete the form. Complete the enclosed paper forms, and mail them to the Board. Call 1-866-396-8314. A Board employee will complete the form with you.
Health Care Bills Do not pay your doctor or hospital. Those bills are paid by the insurer unless the Board disallows your case. If your case is disputed, the providers are paid when the Board decides your case. If the Board decides against you, or if you don’t pursue a case, you will have to pay the doctor or hospital.
Your employer’s insurance covers medically necessary drugs and equipment your doctor prescribes. You’re also entitled to carfare or necessary expenses incurred when traveling for treatment. (Get receipts for those expenses.)
Claimant Information Packet
NEW YORK STATE WORKERS' COMPENSATION BOARD
Generally, you can choose any doctor authorized by the Board. You can also use occupational health clinics. However, if your employer’s insurer has a preferred provider organization to provide care for workers' compensation injuries, you must get your initial treatment from those providers. If that insurer also has a pharmacy or diagnostic network, you must get service within these networks. If the carrier uses these networks, it must also tell you its service providers and how to use them.
Benefits for Lost Wages You are entitled to a portion of your lost wages if your injury affects you in one or more ways:
1. It keeps you from work for more than seven days; 2. Part of your body is permanently disabled; 3. Your pay is reduced because you now work fewer hours or do other work.
An employer or insurer can accept your claim and begin paying your lost wage benefit promptly. Sometimes, employers and carriers dispute a claim. When that occurs, the Board strives to resolve most cases within 90 days.
You may hire an attorney or licensed representative, who can be helpful with complex or disputed claims, but it isn’t required. The Board sets their fees and they will be deducted from your lost wages award. You or your family should not pay anything directly to your attorney or licensed representative.
If your case is disputed, you may receive disability benefits while the case is heard. You’d pay them back out of your lost wages award. To get a DB-450 form, visit www.wcb.state.ny.us/content/main/forms/db450.pdf or a Board office, or call (800) 353-3092.
Help is Available People sometimes need help getting back to work. Your employer may have a return to work program that can get you back to work in light duty or an alternative position while you heal. An injury can also cause family or financial problems. The Workers' Compensation Board has rehabilitation counselors and social workers to help. Call (877) 632-4996 for more assistance.
What’s Next? Your employer or its insurance carrier will contact you if your claim is accepted. When that happens, your treatment will be paid and lost wage benefits begin. If your case is challenged, the Board will notify you about resolving the case. If more information is necessary, the Board will contact you and tell you how to file it.
Important Contact Information Workers’ Compensation Board (877)632-4996 [email protected] Disability Benefits (800)353-3092 www.WCB.State.NY.US NYS Bar Association Lawyer Referral and Information Service
(800)342-3661 [email protected].
C L A I M N U M B E RTHE CITY OF NEW YORK
WORKERS' COMPENSATION CLAIM INITIATION
EMPLOYEE STATEMENT
INJURED EMPLOYEE NAME SOCIAL SECURITY NUMBERFIRST NAME M.I. LAST NAME
NAME
SIGNATURE
(PLEASE PRINT) TITLE TEL.#
DATE
FISA FORM WCS-110 (1/01)
EMPLOYEE'S
ADDRESS
STREET
LOCATION
BORO, CITY
OR TOWN
APT #, FL.#,
BOX #
ZIPSTATE
DATE OF ACCIDENT / INJURY
MM DD Y YYYTIME OF ACCIDENT
AM PMH H MM:
(AREA CD)
WORK
TEL #
EXTENSION
(AREA CD)
HOME
TEL #
DATE OF STATEMENT
M DD Y YYYM# OF
WITNESS(ES)
SUPERIOR NOTIFIED
FIRST NAME M.I. LAST NAME DATE FIRST NOTIFIED
M D D Y YYYM
TITLE
(AREA CD)
WORK
TEL #
EXTENSION
DESCRIBE LOCATION WHERE ACCIDENT OCCURRED
CONTINUATION
#1 ATTACHED
DESCRIBE FULLY HOW ACCIDENT OCCURRED
CONTINUATION
#2 ATTACHED
DESCRIBE OBJECT OR SUBSTANCE THAT CAUSED INJURY
CONTINUATION
#3 ATTACHED
DESCRIBE NATURE AND EXTENT OF INJURY (INCLUDING AFFECTED BODY PARTS)
CONTINUATION
#4 ATTACHED
Chapter 1
Section B26 - Worker's Compensation
OPTION 1
Procedure: Initiate Option 1
Exhibit B26-3: Form DP2002
THE CITY OF NEW YORK
Election of rate of Charge Against Annual and /or Sick Leave Balances
for Absence Due to Injury Sustained in the Performance of Official Duties
(Pursuant to Regulation 7.0 of the Leave regulations for employees who are under the Career and Salary Plan)
INSTRUCTIONS: The injured employee, or an authorized person action in his behalf, should submit this
election notice (in duplicate) to the head of his department or agency within the first seven calendar
days of absence due to injury sustained in the performance of official duties.
I, employed in
(Print name of injured employee) (Print name of City department or agency)
in a position which is subject to the Leave regulations for employees who are under the Career and Salary Plan, or my
authorized agent, do hereby elect the option designated below, subject to the conditions attached thereto, as the one to be
applied in determining the charge, if any, to be made against my annual and/or sick leave balances for absence due to injury
sustained in the performance of my official duties.
(Check one option only)
OPTION 1: I elect to receive the difference between the amount of my weekly salary and the compensation
rate, subject to the following conditions:
(a) A pro-rated charge shall be made against my sick leave and/or annual leave balances equal to the
number of working days of absence less the number of working days represented by the Worker's
Compensation payments, and;
(b) My accrued sick leave and/or annual leave balances, or such leave credits advanced to me in accordance
with the Career and Salary Plan Leave regulations, are adequate to meet the charges made against
them for supplementary pay, and;
(c) The injury sustained by me was not the result of my willful gross disobedience of safety rules or my
willful failure to use a safety device, nor was I under the influence of alcohol, or narcotics at the time
of injury, nor did I willfully intend to bring about injury or death upon myself or another, and;
(d) Such medical examinations will be undergone by me as requested by the Worker's Compensation
Division of the Law Department and my agency, and when found fit for duty by said physicians,
I shall return to my employment.
OPTION 2: I elect to receive Worker's Compensation benefits in their entirety with no charge against sick
and/or annual leave.
Injured employee's signature
This shaded section
should be completed only
if the injured employee
cannot sign and must
designate an authorized
person to sign in his
behalf
Date
Authorized designee's name (Print)
Authorized designee's address
Witness' name (Print)
Witness' address
Witness' signature
Relationship to employee
Date
Issued 02 /15 /93 8
C L A I M N U M B E RTHE CITY OF NEW YORK - WORKERS' COMPENSATION CLAIM INITIATION
Supervisor's/Agency - "REPORT OF INJURY"
INJURED EMPLOYEE NAME EMPLOYEE IDFIRST NAME M.I. LAST NAME
(CONTINUED ON REVERSE SIDE)
EMPLOYEE'S ADDRESS
STREETLOCATION
BORO, CITYOR TOWN
APT #, FL.#,BOX #
ZIPSTATE
DATE OF ACCIDENT / INJURY TIME OF ACCIDENT
AM PM:WAS EMPLOYEE ABSENT
DUE TO INJURY?
YES NO
INITIAL ABSENCE DATE INITIAL ABSENCE TIMEAM PM:
DID EMPLOYEE FOLLOW STANDARDPROCEDURES AT TIME OF ACCIDENT?
YES NO
IF NO, DETAILSREQUIRED
CONTINUATION #3 ATTACHED
CONTINUATION #2 ATTACHED
DID EMPLOYEE'S ACTION OR BEHAVIOR CONTRIBUTE TO THE ACCIDENT?
YES NO
IF YES, DETAILSREQUIRED
CONTINUATION #4 ATTACHED
ARE DISCIPLINARY ACTIONS PENDINGOR CONSIDERED AGAINST EMPLOYEE?
YES NO
IF YES, DETAILSREQUIRED CONTINUATION
#5 ATTACHED
DOES THE AGENCY RECOMMEND TO CONTROVERT?
YES NO
IF YES, DETAILSREQUIRED
CONTINUATION #6 ATTACHED
ARE YOU AWARE OF PRE-EXISTING CONDITIONS?
YES NO
IF YES, EXPLAINCONDITION(S)
CONTINUATION #7 ATTACHED
NAMEFIRST LASTM.I.
ADDRESS STREETLOCATION
BORO, CITYOR TOWN STATE ZIP PLUS 4
NAME FIRST LASTM.I.
ADDRESS STREETLOCATION
BORO, CITYOR TOWN STATE ZIP PLUS 4 D
OCTO
R
DOC
TOR
MONTH DAY YEAR MONTH DAY YEARHOUR MINUTE
IS EMPLOYEE EXPECTEDTO RETURN TO WORK?
YES NO
INJURED WORKER'S WORK WEEKSUN MON TUE WED THU FRI SAT
(ENTER AN "X" FOR DAYS USUALLY WORKED)
HAS EMPLOYEE RETURNED TO WORK?
YES NO
RETURN TO WORK DATE
DATE NOTICE PROVIDED
SUPERVISOR'SFIRST NAME M.I. LAST NAME
TITLE (AREA CD) EXTENSIONWORK TELEPHONE #
WAS ACCIDENT ONEMPLOYER'S PREMISES?
YES NO
DID ACCIDENT OCCURDURING WORK HOURS?
YES NO
DID ACCIDENT OCCURDURING LUNCH BREAK?
YES NO
WAS EMPLOYEE TRAVELING TO/FROM WORK?
YES NO
WAS EMPLOYEE TRAVELINGBETWEEN WORK SITES?
YES NO
DID ACCIDENT OCCUR AT NORMALWORK SITE LOCATION?
YES NO
IF NO, EXACT LOCATION AND COUNTYOF ACCIDENT REQUIRED
WAS EMPLOYEE ON SPECIAL OR WORK RELATED FIELD ASSIGNMENT?
YES NO
IF YES, DESCRIBEFIELD ASSIGNMENT
CONTINUATION #1 ATTACHED
WAS INJURY WITNESSED BY SUPERVISOR? YES NO INJURY DESCRIPTION AS WITNESSED BY SUPERVISOR OR AS REPORTED MUST BE PROVIDED BELOW
MONTH DAY YEAR
MONTH DAY YEAR
HOUR MINUTE
TIME EMPLOYEE BEGAN WORK
AM PM:HOUR MINUTE
HAS THE EMPLOYEE GIVEN YOU NOTICE OF INJURY/ILLNESS?
YES NO
IF YES, NOTICE WAS GIVEN TO: ORALLY IN WRITING
WAS EMPLOYEE PAID FOR A FULL DAY ON THE DAY OF THE INJURY/ILLNESS? YES NO
MONTH DAY YEAR
UNKNOWN
NONERECEIVED
DOCTOR’SON SITE CHILD/ HOSPITAL/EMERGENCYROOM
UNKNOWNHOSPITAL STAYOVER 24 HOURS
WHO TREATED THE EMPLOYEE AND WHERE?
WHAT WAS THE DATE OF EMPLOYEE’S FIRST TREATMENT? WHERE DID THE EMPLOYEE RECEIVE FIRST MEDICAL URGENT CAREOFFICETREATMENT FOR THIS INJURY/ILLNESS?
IS THE EMPLOYEE STILL BEING TREATED FOR THIS INJURY/ILLNESS?
YES NOIF YES, PLEASE ENTER THE NAME AND ADDRESS OF TREATING DOCTOR(S) IN THE DOCTOR SECTION BELOW.
IF ACCIDENT DID NOT OCCUR AT NORMAL WORK SITE, AN EXPLANATION OF WHY EMPLOYEE WAS AT ACCIDENT SITE ISREQUIRED
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 NOIF YES, NAME THE DOCTOR(S) WHO TREATED THE PREVIOUS INJURIES/ILLNESSES (IF KNOWN):
FISA FORM WCS-100 (4/09)
INJURY DESCRIPTION (SEE CODE TABLE FOR DETAILED INJURY, CAUSE & BODY PART DESCRIPTION CODE BREAKDOWN
NATURE OF
INJURY
INJURY TYPE INJURY CODESI OD
SPECIFICINJURY
OCCUPATIONALDISEASE
DESCRIPTION
CONTINUATION #8 ATTACHED
CAUSEOF
ACCIDENT
CAUSE CODE CAUSETYPE
(CHECK ONE)
EXPOSURE(EX)
STRUCK/INJURED(SK)
FALL/SLIP(FS)
CUT/PUNCTURE(CP)
STRIKING AGAINST/STEP ON(SA)
STRAIN/INJURED (SN)
CAUGHT BETWEEN(CB)
MISCELLANEOUS CAUSE(MS)
MOTOR VEHICLE(MV)
BODY PART(S) AFFECTED (INDICATE INJURED BODY PART CODE, DESCRIPTION AND SIDE(S) AFFECTED, IF APPLICABLE) BODY SECTION
CODESBODY
SECTION
PARTCODE
BODYSECTION
PARTCODE
DESCRIPTION:LEFT
RIGHT
BOTH
DESCRIPTION:LEFT
RIGHT
BOTH
PARTCODE
PARTCODE
BODYSECTION
BODYSECTION
DESCRIPTION:LEFT
RIGHT
BOTH
DESCRIPTION:LEFT
RIGHT
BOTH
BODYSECTION
BODYSECTION
DESCRIPTION:LEFT
RIGHT
BOTH
DESCRIPTION:LEFT
RIGHT
BOTH
EMPLOYEE'S JOB DESCRIPTION
JOB TASKAT TIME
OF INJURY
FUNCTIONAL TITLE & DESCRIPTION (ATTACH JOB DESCRIPTION IF AVAILABLE)TYPICAL
WORKDAY
(8 HR. MAX.)
SITTING STANDING WALKING
:
TYP
ICA
L W
OR
KD
AY T
AS
KS
INDI
CATE
WO
RKDA
Y AC
TIVI
TY % ACTIVITY
BENDING / SQUATTING
CLIMBING
KNEELING
LIFTING * Complete LiftingDetail Section
REACHING ABOVE SHOULDER
PUSH / PULL
0 %(N / A)
A
A
A
10 %(MINIMAL)
B
B
C
C
C
20 %(OCCASIONAL)
D
D
D
35 %(MODERATE)
E
E
E
50 %(FREQUENT)
F
F
F
F
70 - 100 %(CONTINUOUS) *LIFTING
UP TO 10 POUNDS
11 TO 20 POUNDS
21 TO 30 POUNDS
31 TO 50 POUNDS
OVER 50 POUNDS
0 %(N / A)
A
A
A
A
A
B
B
B
B
B
C
C
C
C
C
20 %(OCCASIONAL)
D
D
D
D
D
35 %(MODERATE)
E
E
E
E
E
50 %(FREQUENT)
F
F
F
F
F
70 - 100 %(CONTINUOUS)
F
FA
A
B
B
B
C
C
C
D
D
D
E
E
EA B
LIFT
ING
DETA
ILS
IS KEYBOARD USED?
YES NO IF YES,HOW MANY HRS
PER WEEK?
ARE HANDS USED FOR NON KEYBOARD REPETITIVE MOTION?
YES NO IF YES, EXPLAIN WHAT OTHER REPETITIVE MOTIONS ARE PERFORMED?
DID ACCIDENT INVOLVE A MOTOR VEHICLE? YES NO IF YES, WAS VEHICLE REGISTERED TO
THE CITY OF NEW YORK?YES NO USE OF CITY
VEHICLE AUTHORIZED?YES NO EMPLOYEE STRUCK
BY CITY VEHICLE?YES NO EMPLOYEE DRIVING
A CITY VEHICLE?YES NO
WAS EMPLOYEE AVEHICLE PASSENGER?
YES NOWAS INJURED ON PUBLICTRANSPORTATION?
YES NO
DID EMPLOYEE DIE FROM INJURY?IF YES, ANSWER THE FOLLOWING QUESTIONS
YES NO DATEEMPLOYEE DIED
TIME EMPLOYEE DIED
AM PM:NAME OF NEARESTRELATIVE
FIRST M.I. LAST NAME
RELATIONSHIPHOME
TELEPHONE #
ADDRESS STREET LOCATION(INCLUDE APT/FL#)
BORO, CITYOR TOWN
IDENTIFY PERTINENT DOCUMENTATION(e.g. Police Report, Safety Reports, etc.)
CONTINUATION #10 ATTACHED
WAS INJURY CAUSED BY ASSAULT ON THE JOB? YES NO IF YES, PROVIDE INFORMATION BELOW
ASSAILANT WAS: CO - WORKEROFFENDER
FRIEND, FAMILY OR ACQUAINTANCEOWNER / OPERATOR
CLIENTOUTSIDE CONTRACTOR
OTHER
ASSA
ULTE
D BY NAME OF
ASSAILANTFIRST M.I. LAST NAME
ADDRESS STREET LOCATION(INCLUDE APT/FL#)
BORO, CITYOR TOWN
HOMETELEPHONE #
WORKTELEPHONE #
CAN YOU PROVIDE DETAILED EVENTS PRECEDING ASSAULT?
YES NO
IF YES,EXPLAIN
DID ASSAULT INVOLVEA PERSONAL MATTER?
YES NO
IF YES,EXPLAIN
CONTINUATION #11 ATTACHED
CONTINUATION #12 ATTACHED
DID ASSAULT INVOLVEWORK RELATED MATTER?
YES NO
IF YES,EXPLAIN
CONTINUATION #13 ATTACHED
DID THE EMPLOYEE START,PROVOKE OR PROLONG THE
ASSAULT IN ANY WAY?YES NO
IF YES,EXPLAIN
CONTINUATION #14 ATTACHED
PREPARED BY(Please Print)
SIGNATURE
TITLE
TEL #DATE
HN(HEAD/NECK)
UE(UPPER)
TR(TRUNK)
LE(LOWER)
DESCRIPTION CONTINUATION #9 ATTACHED
CONTINUATION #12 ATTACHED
:
EXTENSION
INDICATE THE PERCENTAGE OF WEIGHT LIFTED PER CATEGORY DURING A TYPICAL WORKDAY
IF YES,EXPLAIN
PARTCODE
PARTCODE
10 %(MINIMAL)
:HOUR MINUTE HOUR MINUTE HOUR MINUTE
DOES EMPLOYEE OWNTHE VEHICLE?
YES NO
EMPLOYEE’S JOBWAS (CHECK ONE):
FULL TIME
PART TIME
ADDITIONAL INFORMATION:
WAS AN OBJECT (E.G HAMMER, ACID) INVOLVED IN THE INJURY/ILLNESS? YES NOIF YES, WHAT WAS IT?
YES NOIS CLAIMANT A SEASONAL EMPLOYEE?
STATE ZIP PLUS 4
STATE ZIP PLUS 4
MONTH DAY YEAR HOUR MINUTE
C L A I M N U M B E RTHE CITY OF NEW YORKWORKERS' COMPENSATION CLAIM INITIATION
WITNESS STATEMENTINJURED EMPLOYEE NAME SOCIAL SECURITY NUMBER
FIRST NAME
FIRST NAME
M.I. LAST NAME
LAST NAMEW I T N E S S I N F O R M AT I O N
M.I.
STREET LOCATION (INCLUDE APT / FL #)
STATE ZIP PLUS 4
(AREA CD) (AREA CD)
HOMEADDRESS
BORO, CITYOR TOWN
WORK TEL # HOME TEL#
ARE YOU A CITY
EMPLOYEE?
YESNO
RELATIONSHIP TO INJURED DATE OF ACCIDENT / INJURY TIME OF ACCIDENT
AM PM
LIST OTHER PERSONS
WHO ALSOMIGHT HAVE WITNESSED ACCIDENT
ATTACH NAMES OFADDITIONALWITNESSES
CONTINUATION ATTACHED
FIRST NAME M.I. LAST NAME
DESCRIPTION OF ACCIDENT - INCLUDING LOCATION
NAME
SIGNATURE
(PLEASE PRINT) TITLE
CONTINUATION ATTACHED
TEL.#
DATE
FISA FORM WCS-120 (8/00)
:MONTH DAY YEAR HOUR MINUTE
SOCIAL SECURITY NUMBER