EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE IN EMPLOYMENT STATUS RESULTING FROM INJURY

Sep 19, 2026

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Employer report template for notifying the Workers’ Compensation Board of any change in an injured employee’s employment status after an initial First Report of Injury or a prior Form C-11/EC-11. The form covers changes such as return to work, discontinuance of work, adjustments to regular work hours, and increases or reductions in wages. It requires complete claim and party information, insurer and employer details, dates related to loss of work and return, employment status change tables, and a fraud warning statement.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Claim and Filing Instructions

Claim Information (Required Numbers)

Employee Information

Employer Information

Insurer Information

Loss of Time and Return-to-Work Dates

Employment Status and Wage/Hour Changes

Fraud Warning

Prepared-By Section

# EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGEIN EMPLOYMENT STATUS RESULTING FROM INJURY PO Box5205,Binghamton,NY 13902-5205 ·Web Upload Link:https:/wcbdoc.services.conduent.com/·Email Filing:wcbclaimsfiling@wcb.ny.gov This report is to be filed directly with the Chair,Workers'Compensation Board as soon as the employmen status of an injured employee,asreported 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.A copy should also be sent toyour insurer. Claim Information -ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS Date of Injury/llness: WCB Case\#: Claim Administrator Claim(Carrier Case)\#: Employee Information First Name: Last Name: Mailing Address: Line 2: Zip Code: Country: City: Daytime phone\#: Email Address: Social Security\#: Date of Birth: Employer Information Employer Name: Mailing Address: Line 2: Zip Code: Country: City: State: Employer Phone\#: Federal Tax ID\#: The Tax ID\#is the (check one):OSSN OEIN Insurer Information Insurer Name: Insurer ID(W\#):W Mailing Address: State: Zip Code: Country: City: Insurer Phone\#: Date of first full day employee lost from work: Date employee first returned to work: Loss of time resulting from the above injury since initial date of lost time or last C-11 filed with the Board: | Loss of Time
Start Date | Return To Work Date | Reason | | --- | --- | --- | | | | | As a result of the above injury,was there an increase or decrease in hours worked or wages paid?O Yes ONo If yes,enter status of change below: | Employment Status | Effective Date | Hours per Day | Days per
Week | Earnings | Remarks | | --- | --- | --- | --- | --- | --- | | Prior to Injury | | | | | | | Changed To | | | | | | | Anemployer or insurer,or any employee,agent,or person acting on behalf of an employer o insurer,who KNOWINGLY MAKESAFALSE STATEMENTOR
REPRESENTATION as to a material fac in the course of reporting,investigation of,or adjusting a claim for any benefit or payment under this chapter o the
purpose of avoiding provision ofsuch payment or benefit SHALL BE GUILTY OFA CRIME AND SUBJECT TO SUBSTANTIALFINES AND IMPRISONMENT | | --- | Prepared By: | Last Name: | First Name: | | --- | --- | | Employer Name: | | | Official Title: | Phone\#: | | Email Address: | Date of this report: | MI:

FAQs

When must this report be filed?

File it directly with the Chair of the Workers’ Compensation Board as soon as the injured employee’s employment status changes from what was reported on the First Report of Injury or a prior Form C-11 or EC-11.

What types of employment status changes does the report cover?

It includes return to work, discontinuance of work, increases or decreases in regular hours, and increases or reductions of wages.

What information must be included for all communications?

Communications must include the Date of Injury/Illness, WCB Case #, and the Claim Administrator Claim (Carrier Case) #.

Sep 19, 2026

Upload by Aditya