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Get NY C-11 2011-2024

Date of first full day employee lost from work C-11/EC-11 11. Nature of Injury 12. Date employee returned to work 13. STATE OF NEW YORK WORKERS COMPENSATION BOARD EMPLOYER S REPORT OF INJURED EMPLOYEE S CHANGE IN EMPLOYMENT STATUS RESULTING FROM INJURY This report is to be filed directly with the Chair Workers Compensation Board at the address shown on reverse side as soon as the employment status of an injured employee as reported on First Report of Injury or on a previous Form C-11 or EC-11 is changed. Change in employment status includes return to work discontinuance of work increase or decrease of regular hours of work and increase or reduction of wages. Has injured person died If yes give date of death Name and address of nearest known relative Date of this Report Tel. No.Firm Name Prepared By Official Title C-11 1-11 C-11 INSTRUCTIONS TO THE EMPLOYERS Reports should be sent directly to the Workers Compensation Board New York State Workers Compensation Board PO Box 5205 Binghamton NY 13902-5205 Statewide Fax Line 877-533-0337 THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. C-11 1-11 Reverse www. A copy should also be sent to your insurance carrier. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W*C. B. Case Number 2. Carrier Case Number 3. Carrier Code Name 5. Claimant s Soc* Sec* No* 4. Date of Injury Address to which notice should be sent Give Number and Street City State and Zip Code Apt. No* 6. Injured Person 7. Employer 8. Carrier 9. Date of most recent Employer s Report filed check x give date filed First Report of Injury 10. a Change of employment status resulting from above injury Employment Status Hours per Day Days per Week Earnings Occupation Prior To Injury Changed To b Date of this change in employment status c Remarks 14. Loss of time resulting from above injury since first return to work From Mo. Day Year Reason 15. Is injured person still under physician s care If yes give name of physician 16. A copy should also be sent to your insurance carrier. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W*C. B. Case Number 2. Carrier Case Number 3. Carrier Code Name 5. Claimant s Soc* Sec* No* 4. Date of Injury Address to which notice should be sent Give Number and Street City State and Zip Code Apt. W*C. B. Case Number 2. Carrier Case Number 3. Carrier Code Name 5. Claimant s Soc* Sec* No* 4. Date of Injury Address to which notice should be sent Give Number and Street City State and Zip Code Apt. No* 6. Injured Person 7. Employer 8. Carrier 9. Date of most recent Employer s Report filed check x give date filed First Report of Injury 10. a Change of employment status resulting from above injury Employment Status Hours per Day Days per Week Earnings Occupation Prior To Injury Changed To b Date of this change in employment status c Remarks 14. Loss of time resulting from above injury since first return to work From Mo. Day Year Reason 15. Is injured person still under physician s care If yes give name of physician 16. .

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