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\nThis 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.  \nClaim Information -ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS  \nDate of Injury/llness:              \nWCB Case\\#:                  \nClaim Administrator Claim(Carrier Case)\\#:                                  \nEmployee Information  \nFirst Name:  \nLast Name:                                                \nMailing Address:                                            \nLine 2:                                                    \n      Zip Code:     \nCountry:              \nCity:                            \nDaytime phone\\#:                                  \nEmail Address:                                            \nSocial Security\\#:                        \nDate of Birth:                \nEmployer Information  \nEmployer Name:                                                                                                                  \nMailing Address:                                  \nLine 2:                                              \nZip Code:            \nCountry:                \nCity:  \n                State:            \nEmployer Phone\\#:                    \nFederal Tax ID\\#:            \nThe Tax ID\\#is the (check one):OSSN OEIN  \nInsurer Information  \nInsurer Name:  \nInsurer ID(W\\#):W           \n                               \nMailing Address:                                    \nState:                \nZip Code:          \nCountry:                \nCity:                          \nInsurer Phone\\#:                              \nDate of first full day employee lost from work:                      \nDate employee first returned to work:                      \nLoss of time resulting from the above injury since initial date of lost time or last C-11 filed with the Board:  \n\n| Loss of Time  \u003Cbr>Start Date   | Return To Work Date   | Reason   |\n| --- | --- | --- |\n|  |  |  |\n\nAs a result of the above injury,was there an increase or decrease in hours worked or wages paid?O Yes ONo  \nIf yes,enter status of change below:  \n\n| Employment Status   | Effective Date   | Hours per Day   | Days per  \u003Cbr>Week   | Earnings   | Remarks   |\n| --- | --- | --- | --- | --- | --- |\n| Prior to Injury   |  |  |  |  |  |\n| Changed To   |  |  |  |  |  |\n\n\n| Anemployer or insurer,or any employee,agent,or person acting on behalf of an employer o insurer,who KNOWINGLY MAKESAFALSE STATEMENTOR  \u003Cbr>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  \u003Cbr>purpose of avoiding provision ofsuch payment or benefit SHALL BE GUILTY OFA CRIME AND SUBJECT TO SUBSTANTIALFINES AND IMPRISONMENT   |\n| --- |\n\nPrepared By:  \n\n| Last Name:   | First Name:   |\n| --- | --- |\n| Employer Name:   |  |\n| Official Title:   | Phone\\#:   |\n| Email Address:   | Date of this report:   |\n\nMI:","cbCaiao3Prq9dkqv","https://ap.wps.com/l/cbCaiao3Prq9dkqv","pdf",1474053,"English","# Claim and Filing Instructions\n# Claim Information (Required Numbers)\n# Employee Information\n# Employer Information\n# Insurer Information\n# Loss of Time and Return-to-Work Dates\n# Employment Status and Wage/Hour Changes\n# Fraud Warning\n# Prepared-By Section","[{\"question\":\"When must this report be filed?\",\"answer\":\"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.\"},{\"question\":\"What types of employment status changes does the report cover?\",\"answer\":\"It includes return to work, discontinuance of work, increases or decreases in regular hours, and increases or reductions of wages.\"},{\"question\":\"What information must be included for all communications?\",\"answer\":\"Communications must include the Date of Injury/Illness, WCB Case #, and the Claim Administrator Claim (Carrier Case) #.\"}]","EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE IN EMPLOYMENT STATUS RESULTING FROM INJURY | PDF",1789853865]