FIRST REPORT OF INJURY FORM C-2F
- A claim is initiated by completing a New York State
Employer’s Report of the Work-Related
Injury/Illness (C-2F) form.
- This form must be completed by the
pastor, administrator or supervisor.*the injured Employee is NOT permitted to complete the C-2F form. The New York State Employer’s Report (C-2F
1-14) can be obtained at the Risk Management portal website, under Report a
Claim heading or contacting Risk Management at 315-470-1495.
- In completing the C-2F form, please do not omit any pertinent
information. If the C-2F form is
not fully completed, the incomplete form may be returned to the
employer for completion.
- Employees should be aware that on-the-job injuries should be
documented and reported to their direct supervisor immediately.
- Note - the C-2F(1-14) Employer’s First Report of
Work-Related Injury form MUST be filled out and sent to
Risk Management no matter how minor the injury.
FIRST REPORT OF INJURY C-2F FORM - Download and print out this PDF form to fill out.
Fax the (C-2F) and any attachments you may have to:
Office of Risk Management @
315-474-6890
or email to: bdoran@syrdio.org and mail the originals to:
ROMAN CATHOLIC DIOCESE OF SYRACUSE
ATTENTION: RISK MANAGEMENT
240 EAST ONONDAGA STREET
SYRACUSE, NY 13202
UMR (formerly POMCO) INFORMATION SHEET FOR INJURED EMPLOYEES - this is the company that handles our Workers Compensation claims, this document contains addresses and phone number information for employees that are injured on the job.
UMR Risk Management Billing information sheet for injured Employees - Please print this sheet for your doctor's billing office.
STATEMENT OF WAGES C-240 FORM
- The C-240 Statement of Wage Earnings form is used only for Workers’
Compensation claims. This form is required by the New York State Department of Workers’
Compensation to calculate an injured employee’s weekly disability benefits
based on their gross yearly salary from the date of injury BACK one year.
- If attaching payroll information, do not submit page 2. All attachments should include the Injured Worker's full name, WCB Case # and Date of Injury/Illness.
- The C-240 form will be sent to the employer by UMR (formerly POMCO), when required. Please complete
and return the form immediately to the UMR – 2425 James Street, Syracuse
NY 13206-0325. This form is required back to the Workers' Comp Board within 10 days of request by the Board.
- Remember days worked represent days paid, which could include days paid
with earned sick or vacation time.
- The C-240 form must be fully completed or the Workers’
Compensation Board will return the form which could jeopardize or delay
an injured persons benefits.
- Remember to answer all questions and fill in all of the boxes
for each pay period giving the total days worked and total
gross amount paid. (Can use 26
weeks)
- The boxes for the Workers’ Compensation Board Case Number, and
Carrier’s Case Number will be filled in by our (TPA) UMR. If you have any questions please feel
free to contact Bill Doran at 315-470-1494
C-240 STATEMENT OF WAGES FORM - click to download. This form must be download to your computer to open and work properly. If you are receiving the "Please wait . . ." prompt, you must download the form for it to open, once you download it you can type right on the form.
C-11 FORM “CHANGE IN WORK STATUS OR RETURN TO WORK” - click to download and open to complete
The C-11 form is required by the New York State
Department of Workers’ Compensation when a change in work status occurs as a
result of a work-related injury. A
change of employment status includes discontinuance of work, return to work, increase
or decrease of regular hours of work and increase or reduction of wages.
The C-11 form is mandatory and the only form the
Workers’ Compensation Board will accept for information regarding the injured
employee’s work status. The C-11 Form
must be completed as soon as an employer knows that an employee is missing time
from work due to a work-related injury.
Call our (TPA) UMR immediately when an
employee’s returns-to work date is known, to avoid an over payment in wage
benefits or the Risk Management office at 315-470-1495.
Fully complete and sign the C-11 form and mail it to
UMR at 2425 James Street, Syracuse, NY 13206, within 24 hours from
a date an employee returns-to-work and keep a copy for your records. UMR's fax number is 315-433-5473.
C-11 FORM Change in Status or Return to Work- click to open and download form to fill out
EMPLOYER'S REIMBURSEMENT REQUEST FORM C-107
INSTRUCTIONS FOR COMPLETING THE C-107, "EMPLOYER'S REIMBURSEMENT REQUEST FORM"
WORKERS' COMPENSATION FORMS
