Claim Forms – Things to know:

Claim Forms

Some claims will require additional forms as outlined below. All forms should be sent to our office by email claims@keevily.com or fax 914-381-1134.

C240 Form:  Employer’s Statement of Wage Earnings (Prior to the Date of Accident)

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This form should be completed any time the lost time exceeds the 7 calendar day waiting period. This will provide the Carrier with the necessary information in order to calculate an average weekly wage which will be the basis for the Workers’ Compensation benefit.

  • Give gross weekly earnings for the 52 week period immediately prior to the date of the accident.
  • If the injured worker has not worked at the same work for a year or a substantial part of the year give the weekly gross earnings of another employee of the same class who has worked for a year or a substantial part of the year prior to the date of the accident.

C11 Form: Notice of Return to Work / Change in Employment Status

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Form C-11 must be completed as soon as the injured worker’s employment status changes from what was reported on the eFroi or previously submitted C-11.

Change in employment status, if related to the injury, includes the following:

  1. Return to work
  2. Discontinuance of work
  3. Increase/decrease of regular hours of work
  4. Increase/decrease in wages

C107 Form: Employer’s Request for Reimbursement

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This form is used if the employer has made advance payment of compensation (continued wages) during any period of workers compensation disability. The employer shall be entitled to reimbursement, if desired, at the compensation rate as determined by a Workers Compensation Law Judge. 

  • This is optional and not recommended as you may not receive full reimbursement.
  • Payments will be reimbursed at the Workers’ Compensation rate only.
  • Updated C107 must be completed on a regular basis while injured worker is being paid a continued salary.
  • Reimbursement can only be done at a hearing so it may take some time to receive.
  • Sick or vacation time will need to be credited back to the injured worker once reimbursement is received, unless you elect not to receive reimbursement at which time payment will be made directly to the injured worker.

Considering First Aid? – Things to know:

Considering First Aid?

Employers have the option to pay for the medical treatment out of pocket if the employee did not lose time from work beyond the work day on which the accident occurred and/or received no more than 2 medical treatments. The injury should not result in permanency (example facial scars, ligament or tendon injuries).

  • First aid is not intended for neck, back, hip and joint injuries. Example of first aid claims includes lacerations, foreign body in the eye, nail bed injuries, etc.
  • If a claim is questionable do not pay it as first aid.
  • If the claim goes beyond first aid you must advise us immediately.
  • Employers are required to keep a record of all injuries, including first aid, for 18 years. Please complete first aid form and forward to our office for documentation purposes only.
  • Advise medical provider to bill you directly.
  • Medical bills should be forwarded to our office to determine the amount under the Medical Fee Schedule which you are responsible to pay.

 

Call our office to discuss case if you are not sure it qualifies 1-800-523-5516

Filing NYSIF Work Comp Claims – Things to know:

Claims must be filed within 10 days of injury

WCL Section 110(4), the Board may impose a penalty up to $2,500 against an employer who repeatedly refuses or neglects to file First Report of Injury.

Filing NYSIF Work Comp Claims

  1. Go to www.NYSIF.com\reportinjury
  2. Click filing a timely first report of injury using NYSIF eFROI®
  • The electronic first report of injury report (eFroi) is a legal document and YOUR statement regarding the alleged accident. Do not let the injured worker complete form on your behalf.
  • We suggest you phrase accident details with “injured worker alleges….” Or “injured worker claims…..”.
  • If the accident occurred on a construction OCIP/CCIP job the claim would be reported to the OCIP/CCIP Carrier not NYSIF.
  • Provide copy of Claimant Packet to the injured worker upon filing the claim.
  • Once the eFroi is submitted it will get routed to us and NYSIF for handling. Please forward any supporting documents to claims@Keevily.com