Fill in a Valid C 11 Template

The C 11 form serves as an employer's report detailing changes in an injured employee's employment status following a workplace injury. This document must be submitted to the Workers' Compensation Board promptly if there's a return to work, a discontinuance of work, or any shifts in work hours or wages. To ensure compliance and protect both employee and employer rights, fill out the form by clicking the button below.

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The C-11 form is a critical document that employers must file with the Workers' Compensation Board in New York whenever there is a change in the employment status of an injured employee. This form specifically addresses changes following an injury as reported in the initial First Report of Injury or any preceding C-11 or EC-11 submissions. Key changes that necessitate this report include an employee's return to work, discontinuation of work, alterations in work hours, and variations in wages. Employers are required to act promptly by submitting this report to the Workers' Compensation Board while also ensuring a copy reaches their insurer. In addition to providing basic claim information, the form collects detailed employee and employer information, which includes specifics like the date of injury, contact details, and identification numbers. Moreover, it asks critical questions regarding the loss of time from work and any shifts in wages or hours worked that arise as a result of the injury. Accurate and timely reporting is essential to avoid severe penalties for providing false information, which can result in criminal charges and significant fines. The C-11 plays a crucial role in managing workers' compensation claims effectively, ensuring that all parties are informed and compliant with state regulations.

C 11 Example

EMPLOYER'S REPORT OF INJURED EMPLOYEE'S CHANGE	C-11
IN EMPLOYMENT STATUS RESULTING FROM INJURY

PO Box 5205, Binghamton, NY 13902-5205

Fax #: (877)-533-0337 l Web Upload Link: https://wcbdoc.xrxfs.com/login.aspx l Email Filing: [email protected]

This report is to be filed directly with the Chair, Workers' Compensation Board as soon as the employment status of an injured employee, as reported 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 to your insurer.

Claim Information - ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS

Date of Injury/Illness:

WCB Case #:

Claim Administrator Claim (Carrier Case) #:

Employee Information

Last Name:

First Name:

MI:

Mailing Address:

Line 2:

City:

State:

Zip Code:

Country:

Daytime phone #:

Email Address:

Social Security #:

Date of Birth:

Gender:

Male

Female

Employer Information

Employer Name:

Mailing Address:

Line 2:

City:

State:

Zip Code:

Country:

Employer Phone #:

Federal Tax ID #:

The Tax ID # is the (check one):

SSN

EIN

Insurer Information

Insurer Name:

Insurer ID (W#):

Mailing Address:

Line 2:

City:

State:

Zip Code:

Country:

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? Yes No If yes, enter status of change below:

Employment Status	Effective Date	Hours per Day	Days per	Earnings	Remarks
Employment Status	Effective Date	Hours per Day	Week	Earnings	Remarks
			Week

Prior to Injury

Changed To

An employer or insurer, or any employee, agent, or person acting on behalf of an employer or insurer, 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.

Prepared By:

Last Name:			First Name:	MI:
Employer Name:
Official Title:			Phone #:
Email Address:			Date of this report:
C-11 (6-17)	www.wcb.ny.gov	THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES
		PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

Click for C 11 File

File Breakdown

Fact Name	Description
Name of Form	The C-11 form is officially titled "Employer's Report of Injured Employee's Change in Employment Status Resulting from Injury." This title reflects its purpose clearly.
Filing Requirement	The C-11 form must be submitted to the Chair of the Workers' Compensation Board promptly upon any change in an injured employee's employment status. This includes situations like a return to work, an increase or decrease in hours, or changes in wages.
Governing Law	This form is governed under New York Workers' Compensation Law. It ensures that the rights and benefits of injured workers are appropriately managed and communicated.
Contact Information	For any inquiries or submissions, the form can be faxed to (877)-533-0337, uploaded via the provided web link, or emailed to [email protected].

Guide to Using C 11

After collecting the necessary information regarding an injured employee's change in employment status, it's essential to complete the C-11 form accurately. This is a vital step in ensuring proper communication with the Workers' Compensation Board and maintaining compliance with reporting requirements. Following the listed steps will guide you through the process.

Start by entering the date of injury/illness at the top of the form.
Fill in the WCB case number and the claim administrator's case number next.
Provide the employee's personal details including their last name, first name, and middle initial.
Complete the mailing address section with lines for City, State, Zip Code, and Country.
Record the employee's daytime phone number and email address as well.
Input the social security number and date of birth of the employee.
Select the employee's gender by marking either Male or Female.
Next, turn to the employer's details and enter the employer name and mailing address.
Fill in the employer's phone number and federal tax ID number, selecting either SSN or EIN accordingly.
Provide the insurer name and insurer ID along with their mailing address.
Record the insurer phone number as well.
Add the date of the first full day the employee lost from work.
Enter the date the employee first returned to work and the loss of time resulting from the injury.
Specify the loss of time start date and the return to work date.
Indicate whether there was an increase or decrease in hours worked or wages paid by checking Yes or No.
If applicable, enter the employment status change details, including effective date, hours per day, days per week, and earnings.
Provide remarks if necessary.
Fill in the preparer's details, including last name, first name, middle initial, employer name, official title, phone number, and email address.
Finally, enter the date of this report before submitting.

Make sure to check for any errors before submitting this report. Sending a copy to the insurer is also a necessary step to ensure that all parties are informed. Following these steps accurately helps maintain compliance and support the injured employee's rights and needs.

Get Answers on C 11

What is the purpose of the C-11 form?

The C-11 form serves as an employer's report indicating changes in an injured employee's employment status due to their injury. This includes details about whether the employee has returned to work, stopped working, adjusted their hours, or experienced a change in wages.

When should the C-11 form be filed?

The form should be filed as soon as there is a change in the employment status of an injured employee. This includes changes reported in the First Report of Injury or updates made in prior C-11 or EC-11 forms.

Who should receive the C-11 form?

The completed C-11 form must be sent directly to the Chair of the Workers' Compensation Board. Additionally, a copy should be forwarded to your insurer to keep them informed of the changes.

What information is required on the C-11 form?

The form requires detailed information, including:

Employee's personal details (name, address, phone, social security number)
Employer information (name, address, tax ID)
Insurer details (name, ID)
Information regarding the date of injury, dates of lost time, and return to work
Details on any changes in hours and wages

How does an employer determine if an increase or decrease in hours or wages has occurred?

As an employer, you should compare the employee's initial work hours and wages prior to injury with their current status after the injury. If there has been any notable change, such as a shift in the number of hours worked per day or a change in pay rate, this should be recorded on the form.

What are the consequences of providing false information on the C-11 form?

Providing false statements or misrepresentations on the C-11 form can lead to serious legal repercussions. It is considered a crime, with potential consequences including substantial fines and imprisonment.

Can the form be submitted electronically?

Yes, the C-11 form can be submitted electronically through the Web Upload Link provided on the Workers' Compensation Board website. You may also choose to file it via email at the specified claims filing email address.

What if the employee experiences multiple changes in employment status?

If there are multiple changes in the employee's status, it is essential to file a separate report for each change, as each must be documented accurately to maintain compliance with reporting requirements.

Who is responsible for completing and submitting the C-11 form?

The employer or their designated agent must complete and submit the C-11 form. Ensure that the information recorded is accurate and that the form is submitted in a timely manner to avoid delays in processing claims.

Where can I find additional resources or assistance for completing the C-11 form?

For more information and resources, you can visit the Workers' Compensation Board's official website. They offer guidance and FAQs that can help clarify the process of completing the C-11 form and other related inquiries.

Common mistakes

Completing the C-11 form accurately is crucial for both employers and employees in the context of workers' compensation claims. However, many make common mistakes that can lead to delays or complications in processing. Here are six frequent pitfalls to avoid when filling out this important document.

One mistake people often make is failing to fill out all required fields. Each section of the C-11 form is necessary for accurately reporting an employee’s change in employment status. Missing information, such as the employee's date of birth or social security number, can create significant delays. It is crucial to double-check that every box is completed before submission.

Another common error is incorrect documentation of the employer information. If the employer name or tax identification number is incorrect, it can affect payment processing or liability determination. Be sure to match the information exactly as it appears in your official records. Additionally, using outdated contact information can lead to communication issues, so always confirm that the mailing address and phone number are current.

Individuals often overlook the importance of including the correct dates for key events. Reporting the wrong date of injury or the wrong dates when the employee lost time or returned to work can alter the claims process. This error may lead to disputes regarding eligibility for benefits or the amount due. Careful attention to detail is essential here.

A frequent misstep involves incorrect categorization of changes in employment status. It’s vital to specify whether there has been an increase or decrease in hours or wages accurately. Simply checking “yes” or “no” without specifying the nature of the change can lead to confusion and further inquiries from the Workers’ Compensation Board.

Another mistake is neglecting to communicate with insurance providers. After completing the C-11 form, sending a copy to the relevant insurer is essential. Failing to do so can create gaps in information that complicate the claims process. Ensure that both the Board and the insurer are kept informed about the employee’s status.

Finally, some individuals underestimate the significance of careful language in the remarks section. This section allows for clarification or additional details that may not be covered elsewhere on the form. Using vague descriptions can lead to misunderstandings. Instead, concise and precise explanations will facilitate better communication.

Avoiding these mistakes will help ensure that the C-11 form is processed smoothly. Taking the time to review, verify, and confirm all information can make a significant difference in the effectiveness of the claims process.

Documents used along the form

The C-11 form is essential for reporting changes in an injured employee's employment status due to a workplace injury. It is important to be aware of other forms and documents that might be used alongside the C-11 to ensure comprehensive communication and compliance throughout the workers' compensation process. Below is a list of these forms, along with brief descriptions of their purposes.

First Report of Injury (FROI): This is the initial report submitted to the Workers' Compensation Board following an employee's injury. It provides essential details about the accident and initiates the workers' compensation claim process.
WC-7 Claim Form: This form is completed by the injured employee to formally request benefits under the workers' compensation system. The WC-7 includes information about the worker’s injury and employment details.
EC-11 Notification of Employment Status Change: Similar to the C-11, this form is used to inform the Board of changes in an employee’s work status post-injury, particularly in relation to ongoing wage or workload adjustments.
WCB Form 3: This document is used by health care providers to report on the medical treatment provided to the injured employee. This includes any findings from examinations and the treatment plan moving forward.
Disability Benefits Checklist: This form helps employers and insurers track disability benefits claims related to the worker’s compensation case. It ensures that necessary benefits are considered and allocated throughout the recovery process.
C-62 Authorization for Release of Information: This document authorizes the sharing of medical and employment information between the injured employee and the insurance carrier or Board, facilitating coordination in treatment and compensation.
Claim Status Update Form: Used to provide updates regarding the claim’s progress, this form can help communicate necessary changes or information regarding the injured worker's recovery and return to work status.

Staying organized with these additional forms can streamline the claims process and provide clearer communication among all parties involved. Understanding each form’s purpose ensures compliance with regulations and aids in the proper management of a worker’s compensation case.

Similar forms

First Report of Injury: Like Form C-11, this form provides vital information about the initial incident that caused the injury. It serves to document the event and report it promptly to the Workers' Compensation Board.
EC-11: This form is similar to the C-11 in that it also addresses changes related to the employment status of an injured employee. It serves to communicate adjustments for ongoing cases, ensuring consistent record-keeping.
Claim Status Report: This document details the current standing of a workers' compensation claim. Similar to the C-11, it includes information about changes in a claimant's work capacity or financial situation.
Return-to-Work Form: This form is used to notify relevant parties when an employee is back at work. Like the C-11, its purpose is to provide clear communication regarding the employee's employment status.
Loss of Wages Report: This form captures information about lost wages due to workplace injuries. It aligns with the C-11’s focus on documenting changes that may impact an employee's earnings following an injury.
Notice of Change in Employment Status: This notice informs stakeholders of any modifications in an employee's work situation, making it comparable to the C-11 in its purpose to communicate important status updates.
Medical Release Form: While focused on a different aspect, this form allows healthcare providers to share information about an injured employee’s ability to work, thus impacting employment status similar to the C-11.
Workers’ Compensation Claim Application: This initial application outlines the basic claim details. Like the C-11, it is essential for processing claims and tracking the employee's status throughout the claims process.
Benefit Payment Statement: This document reveals the amounts paid to employees under a claim. It relates to the C-11 by detailing financial implications of employment changes after an injury.
Final Settlement Agreement: While this document deals with the conclusion of a claim, it can contain similar information regarding an employee's transition back to work or changes in their employment status following an injury.

Dos and Don'ts

When filling out the C-11 form, it is important to follow certain guidelines to ensure accuracy and compliance. Here are some key dos and don’ts:

Do provide complete and accurate information. Ensure all sections are filled out thoroughly.
Do submit the form promptly after a change in the employee's employment status.
Don't leave out important details such as dates of injury or contact information.
Don't make false statements or misrepresent facts, as this can result in severe penalties.

Misconceptions

Here are nine common misconceptions about the C-11 form along with clarifications:

The C-11 form is only required when an employee returns to work. Many believe the form is necessary only upon return, but it must be filed for any change in employment status, such as a decrease in hours or wages.
Submitting the C-11 form is optional. The form must be filed promptly when there is a change in the status of an injured employee. Delaying or skipping this step can lead to compliance issues.
All changes to employment status require a new C-11 form. While it’s true that any change should be reported, minor adjustments, such as temporary schedule changes, may not require a new submission if they do not affect compensation.
The C-11 form is only for injuries sustained on the job. This form applies to employees whose injury leads to changes in their employment status, regardless of when or how the injury occurred.
The C-11 must be submitted to the employee’s direct supervisor. This form should be filed directly with the Workers' Compensation Board and also sent to the insurer, not just an internal supervisor.
The C-11 form is only necessary for full-time employees. Part-time employees or those with reduced hours due to injury also require a C-11 to document their employment changes.
You can file the C-11 via email only. While email is one option, the form can also be submitted via fax or through a web upload link, providing flexibility in filing methods.
The C-11 form is only applicable in the state where the injury occurred. Each state has its own requirements. The C-11 form specifically pertains to New York's Workers' Compensation Board regulations.
Failure to file the C-11 does not have serious consequences. Not filing the form, or filing it incorrectly, can result in possible fines and legal issues regarding workers' compensation claims.

Understanding these misconceptions can help ensure timely and accurate reporting, benefiting both employers and employees.

Key takeaways

Filing the C-11 form accurately and promptly is essential for maintaining compliance with workers' compensation regulations. Here are some key takeaways to keep in mind when filling out and using the C-11 form:

Timeliness is Crucial: Submit the C-11 form as soon as there is a change in an injured employee’s employment status. This ensures compliance and helps avoid complications later.
Comprehensive Reporting: Include all necessary details about the employee, employer, and insurer. Missing information can delay processing and lead to confusion.
Understand Employment Status Changes: Employment status changes can include returning to work, stopping work, or alterations in hours and wages. Be clear about what has changed.
Include Important Dates: Note critical dates such as when the employee first lost time from work and when they returned. This documentation helps clarify the timeline of the claim.
Send Copies to Insurers: Don’t forget to send a copy of the completed form to your insurer. This keeps them informed and ensures all parties have the same information.
Be Honest: Any false statements made on the C-11 can lead to severe penalties, including fines and imprisonment. Always provide accurate information.
File Directly with the Board: Make sure to file the report directly with the Workers' Compensation Board. Following the specific submission guidelines is essential for proper handling.
Use Available Resources: Don’t hesitate to utilize the provided web upload link or email for filing. These options may simplify the process and ensure timely submission.

Understanding these key points can make handling the C-11 form simpler and more efficient. Proper attention to detail will help you navigate the sometimes complex world of workers' compensation effectively.