Get What Is New York Form C121

Filling out the What Is New York Form C121 is essential for individuals seeking compensation under workers' compensation law in New York. This guide provides step-by-step instructions to help users complete the form accurately and efficiently online.

Follow the steps to complete your C121 form online easily.

1. Click the ‘Get Form’ button to access the form and open it in the corresponding editor.
2. Provide the W.C.B. case number in the specified field, as well as the carrier's case number and the claimant's Social Security number.
3. Enter the name of the injured or deceased individual in the designated area.
4. Fill in the complete address of the injured or deceased, including street number, city, state, and zip code.
5. Input the name of the employer responsible for the incident.
6. Provide the employer's address, similar to previous steps, including all relevant details.
7. Specify the employer's insurance carrier in the provided field.
8. Document the date of the accident and the place where it occurred.
9. Describe the cause of the accident in as much detail as possible.
10. Indicate the nature of the injury sustained during the accident.
11. List the name of the attending doctor or hospital involved in the treatment of the injury.
12. Provide the address of the attending doctor or hospital.
13. Document the date when the action commenced and the court handling the case.
14. Enter the name and contact number of the attorney representing your case, if applicable.
15. Complete the signature section, confirming the claim, and include the date and contact information.
16. If applicable, fill in the details for dependents in death cases, including their names, addresses, dates of birth, and relationships to the deceased.
17. After completing all necessary sections, save your changes, download, print, or share the form as needed.

Start completing your documents online today for a seamless filing experience.