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 or fax 914-381-1134.

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


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


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


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.