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 Form C-2 or EC-2, 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. A copy should also be sent to your insurance carrier. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. Case Number 3. Carrier Code 5. Claimant's Soc. Sec. No. 4. Date of Injury 2. Carrier Case Number Address to which notice should be sent (Give Number and Street, City, State, and Zip Code) Name 6. Injured Person Apt.No. 7. Employer 8. Carrier 9. Date of most recent Employer's Report filed: (check "x" & give date filed) C-2/EC-2_____________ 10. Date of first full day employee lost from work: ___________________________ C-11/EC-11_____________ 11. Nature of Injury:_________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 12. Date employee returned to work: __________________________________ 13. (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 TO (Mo., Day, Year) 15. Is injured person still under physician's care?______ If yes, give name of physician:______________________________________ 16. 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 C-11 C-11 C-11 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO THE EMPLOYERS Reports should be sent directly to the district offices at these addresses: ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 Peek. (866) 746-0552 For all accidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. Statewide Fax Line: 877-533-0337 www.wcb.state.ny.us THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. C-11 (1-11) Reverse American LegalNet, Inc. www.FormsWorkFlow.com