PO Box 5205, Binghamton, NY 13902-5205 Fax: 877-533-0337 State of New York - Workers' Compensation Board www.wcb.ny.gov REPORT OF WORK-RELATED INJURY OR OCCUPATIONAL DISEASE This form is to be filed with the Workers' Compensation Board within 10 days of a work-related injury or illness. A copy of this report should be provided to your insurance carrier. No hearing will be scheduled at the Board in response to this report of injury. EMPLOYER'S NAME AND MAILING ADDRESS INSURANCE CARRIER'S NAME AND MAILING ADDRESS FILING ENTITY: Employer Carrier Other (If "Other", give name and address.) CARRIER ID NUMBER WWC POLICY NUMBER CARRIER CASE NUMBER EFFECTIVE DATE OF POLICY INJURED EMPLOYEE (First Name, Middle Initial, Last Name) EMPLOYEE'S ADDRESS (Street No. & Name, Apt No., City, State & Zip Code) UNION NAME & LOCAL NUMBER EMPLOYEE'S SOCIAL SECURITY NUMBER DATE OF BIRTH TELEPHONE NUMBER SEX SPECIFIC DETAILS AS TO OCCURRENCE OF INJURY AND PART(S) OF BODY AFFECTED ADDRESS WHERE INJURY OCCURRED DATE OF INJURY TIME OF INJURY DATE SUPERVISOR FIRST KNEW OF INJURY WAS MEDICAL CARE PROVIDED? YES NO IF YES, BY WHOM? DATE(S) MEDICAL CARE PROVIDED: _________________________________________________________________________________________ IS THIS A DEATH CASE? YES NO HAS EMPLOYEE RETURNED TO WORK? Prepared by YES NO IF YES, DATE OF RETURN: ________/________/________ Official Title Date of this Report Telephone Number & Extension ADR-1 (1-11) ADR-1 Prescribed by Chair Workers' Compensation Board State of New York ADR-1 ADR-1 ADR-1 American LegalNet, Inc. www.FormsWorkFlow.com SEE FILING INSTRUCTIONS ON REVERSE THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. FILING INSTRUCTIONS Please note that the ADR-1 Report of Injury form must be submitted to the Workers' Compensation Board within 10 days of a work related injury or illness, as required by 12 NYCRR § 314.2(d)(5). The ADR-2 Final Disposition of Claim form must be filed with the Workers' Compensation Board's local district office within 30 days of the final resolution of a claim through settlement, mediation,or arbitration, as required by 12 NYCRR § 314.7(a). Failure to file the prescribed ADR forms with the Workers' Compensation Board in a timely manner may result in revocation of the parties' authorization to participate in the Alternative Dispute Resolution Pilot Program. ADR-1 (1-11) Reverse American LegalNet, Inc. www.FormsWorkFlow.com