State of New York - Workers' Compensation Board Employer's First Report of Work-Related Injury/Illness C-2F A work-related injury or illness must be reported within 10 days (Per Section 110) of the injury/illness or be subject to a penalty. Employers are not required to submit form C-2F to the Workers' Compensation Board if the employer's insurer will be submitting the accident information electronically to the Board on the employer's behalf. If you need assistance completing this form, please contact your insurer for guidance on the best method of reporting work-related accident information. If you submit this form to the Board, please send it to P.O. Box 5205, Binghamton, NY 13902 and provide a copy to your insurer. Employee Name WCB Case Number (JCN) Claim Administrator Claim Number Date of Injury INSURER / CLAIM ADMINISTRATOR INFORMATION Insurer Name Name Info/Attn Address City Postal Code Claim Admin ID State Country Insurer ID EMPLOYEE INFORMATION First Name Last Name Mailing Address City Postal Code Phone Number Date of Birth Employee SSN Occupation Description State Country Date of Hire Gender Middle Name/Initial Suffix Male Female Unknown C-2F (1-14) Page 1 of 3 www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION Time of Injury Employment Status Estimated Weekly Wage Work Week Type Work Days Scheduled Date Employer Had Knowledge of the Injury Date Employer Had Knowledge of Date of Disability Number of Days Worked Per Week Standard Work Week Sun Mon Tues Fixed Work Week Wed Thurs Fri Varied Work Week Sat EMPLOYEE INJURY Full Wages Paid for Date of Injury Initial Treatment Yes No Employer Paid Salary in Lieu of Compensation Yes No No Medical Treatment Emergency Evaluation Minor On-Site Treatment By Employer Hospitalization Greater Than 24 Hours Minor Clinic/Hospital Treatment Future Major Medical/Lost Time Anticipated Death Result of Injury Yes No Unknown Date of Death Number of Dependents Nature of Injury (i.e. Laceration, Burns, Fracture, Strain, etc) Part of Body (i.e. left arm, right foot, head, multiple, etc) Cause of Injury (i.e. Motor Vehicle, Machine, Strain or Injury by lifting, etc) Accident/Injury Description (see instructions) WORK STATUS Initial Date Last Day Worked Initial Date Disability Began Initial Return to Work Date Return To Work Type Physical Restrictions Return To Work Same Employer Actual Yes Yes Released No No ACCIDENT LOCATION AND WITNESSES Premises (see instructions) Organization Name Street City County Location Narrative State Postal Code Country Employer Lessee Other Witnesses Business Phone Number C-2F (1-14) Page 2 of 3 www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYER INFORMATION Name UI Number Industry Code Info/Attn Mailing Address City Postal Code Physical Addr City Postal Code Contact Name Contact Business Phone Number State Country State Country Employer FEIN Manual Classification Code INSURED INFORMATION Insured Name Insured Type Policy Number ID Policy Effective Date Policy Expiration Date Insured FEIN Insured Self-Insured Uninsured Insured Location ID An employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. The above information is true to the best of my knowledge and belief. If prepared by the employer: Signature of Person Preparing Form Print Name Title Phone Number Date C-2F (1-14) Page 3 of 3 www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com