LIST OF ALL PRESCRIBED FORMS
Formno A-9 Title Agreement to Pay Medical Costs in the Event of Failure to Prosecute or if Compensation Claim is Disallowed Alternative Dispute Resolution Program Report of Injury Modification of Previous Report Notice of Compliance Alternative Dispute Resolution Program Final Disposition on Settlement of Claim. Application for License for a Medical Bureau Application for License for a Laboratory Application of a Voluntary Hospital for X-Ray Laboratory or X-Ray Bureau License Application for Renewal of License to Operate a Medical Bureau Under the W.C.L. Application of a Voluntary Hospital for Renewal of License to Operate an X-Ray Bureau or Laboratory Under the W.C.L. Application for Renewal of License to Operate a Laboratory Under W.C.L. Notice of Compliance - Workers' Compensation Law Notice to Be Posted by Employers Under WCL for Automotive or Horse-Drawn Vehicles Application for Certificate of Workers' Compensation Insurance Statement That Applicant Does Not Require W.C. or D.B. Coverage Notice of Election of an Incorporated Religious, Charitable, Educational or U.S. War Veteran Organization to Bring Executive Officers Under the Coverage of the WCL Notice of Election of a Municipal Corporation or Other Political Subdivision of the State to Bring Executive Officers Under Coverage of the WCL Notice of Election of a Partnership or Sole-Proprietorship to Bring Partners or Self-Employed Persons Under the Coverage of the WCL Notice of Election of a Self-Insured Religious, Charitable or Educational (S.I.) Corporation to Bring Executive Officers Under the Coverage of the WCL Revocation of Election of an Incorporated Religious, Charitable, Educational or U. S. War Veterans Organization to Bring Executive Officers Under the Coverage of the WC Revocation of Election of a Muncipal Corporation or Other Political Subdivision of the State to Bring Executive Officers Under
ADR-1 ADR-1.1 ADR-105 ADR-2 C-100 C-100.1 C-100.2 C-100.3 C-100.4
C-100.5 C-105 C-105.1 C-105.2 C-105.21 C-105.3
C-105.31
C-105.32
C-105.3SI
C-105.4
C-105.41
Page: 1
Formno C-105.4SI
Title the Coverage of the WCL Revocation of Election of a Self-Insured Religious, Charitable or Educational (S.I.) Corporation to Bring Executive Officers Under the Coverage of the WCL Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage Notice of Election of a Not-For-Profit Corp. or a Not-For-Profit Unincorp. Assoc. to Exclude an Unsalaried Exec. Off. From Coverage Pursuant to Sec. 54, Subd. 6 Revocation of Elec. of a Not-For-Profit Corp. or Not-For-Profit Unincorp. Assoc. to Exclude an Unsalaried Exec. Off. From Coverage Pursuant Sec. 54 Sub. 6 Notice of Election to Bring Sheltered Work Participants Under Workers' Compensation Law Revocation of Election to Exclude Corporate Officers from Compensation Coverage Notice of Resolution Adopted by the Board of Fire Comm. of a Fire Dist. Elec. Pursuant to Sec. 54, Subd. 6a of the WCL Not to Provide W. C. Cov. For Officers & Employees Employer's Report of Injured Employee's Change in Employment Status/Notice of Return to Work Claim for Compensation and Notice of Commencement of Third Party Action Notice of Satisfaction of Workers' Compensation Lien from Third Party Recovery Under Sec. 29, Subd. 1&2 Employer's Report of Work Related Accident/Occupational Disease Application for Lump Sum Payment Application for Approval of Non-Schedule Adjustment Employer's Statement of Wage Earnings Preceding the Date of Accident Application for Reopening of Claim More Than Seven Years After Accident Notice of Claim for Reimbursement Out of the Special DB Fund Under Section 15-8 Carrier's Request for Reimbursement of Compensation Payments Under Section 15-8 Carrier's Request for Reimbursement of Medical Expenses Under Section 15-8 Carrier's Request for Reimbursement of Compensation Payments Under Section 14(6) Concurrent Employment Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) & Section 15(8)
C-105.51
C-105.52
C-105.53
C-105.54
C-105.55 C-106
C-11
C-121 C-121.2
C-2 C-21 C-22 C-240 C-25 C-250 C-251 C-251.1 C-251.2
C-251.3
Page: 2
Formno C-256 C-256.1 C-256.2
Title Claim for Reimbursement of Excess Benefits Paid Under a Welfare, Pension or Benefit Plan N.Y. State Employees Retirement System Claim for Reimbursement State Insurance Fund - Claim for Reimbursement of Wages Paid to State Employee Subpoena Subpoena Duces Tecum Medical Proof of Change in Condition in Support of Application for Reopening of Claim for Workers' Compensation Employee's Claim for Compensation Notice of Consent to Utilize An Employer or Carrier Recommended Network or Health Care Provider Statement of Unresolved Issues - Special Part for Expedited Hearings Stipulation Settlement Agreement - Section 32 Attending Doctor's Report (Snapout) Continuation to Carrier/Employer Billing Portion of Form C-4 Statement of Rights Vocational Rehabilitation Assessment Attending Ophthalmologist's Supplementary Report Claim for Compensation in Death Case Proof of Death by Physician Last in Attendance on Deceased Proof of Burial and Funeral Expenses by Undertaker Notice That Right to Compensation Is Controverted Notice of Treatment Issue(s) /Disputed Bill Notice to Chair That Payment of Compensation Has Been Stopped or Modified Notice Regarding Possibility of Processing Case in Conciliation Bureau Employer's Statement for the Purpose of Terminating Status as a Covered Employer Notice of Compliance - Disability Benefits Law Employer's Application for Certificate of DB Insurance Employer Identification Card Employee's Statement of Exempt Status (Under Sec. 235 of the DB Law) Employer's Application for Voluntary Coverage (Employee Contribution Not Required) Employer's Application for Voluntary Coverage (Employee Contribution Required) Application for Self-Insurance Disability Benefits Law - Agreement and
C-26 C-26DT C-27
C-3 C-3.1
C-300.34 C-300.5 C-32 C-4 C-4.1 C-430S C-4VR C-5 C-62 C-64 C-65 C-7 C-8.1 C-8/C-8.6 CB-8 DB-118 DB-120 DB-120.1 DB-125 DB-130 DB-135
DB-136 DB-150 DB-152 Page: 3
Formno
Title Undertaking for Paying Benefits as a Self-Insurer Notice of Termination of Employer's Participation in Self-Insured Association, Union or Trustees Plan Self-Insurer's Annual Financial Statement DBL Self-Insurer's Bond - DBL Rider Changing Sum of Self-Insurer's Bond Rider for Change in Corporate Name of Self-Insurer Notice of Election to Exclude the Sole Shareholder-Officer of the Corporation from DB Coverage Notice of Election to Voluntarily Exclude Spouse From Coverage DB Statement of Rights Notice and Proof of Claim for Disability Benefits of Unemployed Claimant Notice of Satisfaction of Disability Benefits Lien From Third Party Recovery Under Sec. 227, Subds. 1 & 2 Notice and Proof of Claim for Disability Benefits Practitioner's Statement Notice of Total or Partial Rejection of Claim for DB Notice of Disability Benefit Payments Preliminary Claim for Reimbursement of Benefits Paid Under the DBL Insurance Carrier's Report of Claims, Benefits, Employees and Covered Payrolls Employer's Report of Excess Dividends or Rate Credits Self-Insurer's Report of Claims, Benefits, Employees, Contributions and Covered Payrolls Self-Insurer's Report of Excess Employee Contributions DBL - Employer Providing Disability Benefits (Application and Agreement) Plan of an Association of Employers or Employees, Union or Trustees Providing Disability Benefits (Application and Agreement) D.B.L. - Employer's Application to Have Association, Union or Trustee Plan Accepted as Employer's Plan Supplement to Certificate of Insurance (Schedule of Benefits and Contributions) Certificate of Insurance - in Behalf of Association, Union or Trustees Certificate/Cancellation of Insurance Notice of Cancellation of Contract of Ins. for Association, Union or Trustees
DB-159.1
DB-165 DB-179 DB-179.1 DB-179.2 DB-212.3
DB-212.5 DB-271S DB-300 DB-381.3
DB-450 DB-450.5 DB-451 DB-455 DB-470 DB-680 DB-680.1 DB-681
DB-681.1 DB-800 DB-801
DB-802
DB-820.1 DB-820.3 DB-820/829 DB-829.3
Page: 4
Formno DB-840 DB-850 EC-240 FCE-4 GA-700 GSI-1(MC) GSI-1 GSI-1.1
Title Carrier's Designation of Authorized Representatives Application for Acceptance of Insurance Form Employer's Statement of Wage Earnings Practioner's Report of Functional Capacity Evaluation Application for Public Access to Records Application for Municipal Corp. Group Self-Insurance Application for Group Self-Insurance Application for Participation in Group Self-Insurance Plan and Employer's Report of Payroll & Loss Experience Agreement and Undertaking of Employer Group As a Self-Insurer Notice of Termination of Employer's Participation in Group Self-Insurance Plan Health Insurer's Request For Reimbursement Health Provider's Request for Decision on Unpaid Medical Bill(s) Notice to Chair: Health Provider's and Insurer's Withdrawal of Request for Arbitration Practitioner's Report of Independent Medical Examination Claimant's Notice of Independent Medical Examination Statement of Registration, Section 13-n WCL Attending Doctor's Request for Medical Authorization Carrier/Self-Insurer's Objection to Order of the Chair Authorizing Special Services Carrier/Self-Insurer's Objection to Board's Affirmance of Order of the Chair Authorizing Special Services Application for License Under Sec. 13-c, Subd. 3 Agreement of Medical Center Jointly Operated by Labor and Management Representatives Application for License for a Hospital or H.M.O. Notice of Claim for Payment of Medical Bill to Which Carrier Has Not Objected Health Provider's Application for Rating Under the WCB Transmittal Letter: Certificate of Authorization Claimant's Authorization to Disclose Workers' Compensation Records Notice of Retainer and Appearance Application for Fee Application for Representative's License with Fee to Appear on Behalf of Claimants Renewal Application Under Sec. 24-a
GSI-3 GSI-3.1 HIMP-1 HP-1 HP-4
IME-4 IME-5 IME-7 MD-1 MD-3 MD-4
MR-500 MR-500.1
MR-501 MR-54 MR/IME-1 MR/IME-6 OC-110A OC-400 OC-400.1 OC-401.1 OC-401.1R Page: 5
Formno OC-403.1 OC-403.1R OC-403.2 OC-403.2R OC-407 OC-408 OC-409 OT/PT-4 PH-16.2 PS-4 R RB-679 RB-8 RB-8.1 RB-8.2 RB-89 RB-89.1 RFA-1 RFA-2 SI-1 SI-15 SI-15.1
Title Application for License to Appear on Behalf of or Represent Self-Insurer Renewel of Application for License to Appear on Behalf of or Represent Self-Insurer Application by Employee of S.I. Representative to Appear Before the Board Renewel of Application of Licensed Employer Under Section 50-3B or 3D Self-Insurers' Representative's Bond Licensed Representative's Disclosure of Conflict of Interest Initial Application to Take License Representative's Exam Occupational/Physical Therapist's Report Pre-Hearing Conference Statement Psychologist's Report Carrier's Report on Rehabilitation Notice of Carrier's Action on Application For Reopening Request for Reimbursement and Certificate of Accuracy (Form C-8 or VF-8) Request for Reimbursement and Certificate of Accuracy (Uninsured Employer's Fund) Request for Reimbursement and Certificate of Accuracy (Uninsured Employer's Fund) Cover Sheet - Application for Board Review Cover Sheet - Rebuttal of Application For Board Review Claimant' Request for Further Action Carrier's Request for Further Action Application for Self-Insurance Agreement of Parent and Subsidiary Corporations for Consolidated Deposits Resolution of the Board of a Self-Insured Corporation Regarding Consolidated Deposit (Subsidiary Corporation) Agreement of Consolidation of Deposits of Corporation and Inactive Subsidiary Corporations Resolution of the Board of Directors of Corporation Regarding Consolidation of Deposits (Inactive Corp.) Agreement for Consolidation of Deposits of Corporation and Inactive Subsidiary or Predecessor Corp. Resolution of the Board of Directors of Predecessor Corp. Agreement for Payment of Workers' Compensation Liability Certificate of Excess Carrier Evidencing Payment of Claims Under Excess Contract Notice of Election by a Political Subdivision or Fire District to Secure Compensation as a Self-Insurer Agreement of Self-Insurer
SI-15.2
SI-15.3
SI-15.4
SI-15.5 SI-15.6 SI-22 SI-26
SI-3 Page: 6
Formno SI-6 SI-8 SI-8.1 VAW-1
Title Self-Insurer's Report of Payroll for All Operations Self-Insurer's Surety Bond - WC Law Rider Changing Aggregate Sum of Surety Bond Notice to Liable Political Subdivision or Ambulance Service of Volunteer Ambulance Worker's Injury or Death Notice of Compliance with Volunteer Ambulance Workers' Benefit Law Political Subdivision's or Unaffiliated Ambulance Service's Report of Injury to Volunteer Worker Volunteer Ambulance Worker's Claim for Benefits Claim for Volunteer Ambulance Workers' Benefit in Death Case Notice to Liable Political Subdivision of Volunteer Firefighter Injury or Death Notice of Compliance With Volunteer Firefighters' Benefits Law Political Subdivision's Report of Injury to Volunteer Firefighter Volunteer Firefighter Claim for Benefits Claim for Volunteer Firefighter Benefit in Death Case Carrier's Request for Benefit Increase Reimbursement Under Section 51-2, VFBL/VAWBL
VAW-105 VAW-2
VAW-3 VAW-62 VF-1 VF-105 VF-2 VF-3 VF-62 VF/VAW-10
Page: 7