State of New York Forms in Word

Form No.

Title

Price Buy Now

NY ERFA-2 Request For Further Action By Carrier/Employer State of New York – Workers’ Compensation Board $29.00
DRL 236 in Word Statement of Net Worth IN WORD $12.99
DRL 236 in Excel Statement of Net Worth IN EXCEL with automatic calculations $180.00
IT-204-LL Limited Liability Company/ Limited Liability PartnershipFiling Fee Payment Form $12.99
C4 ATTENDING DOCTOR’S REPORT AND CARRIER/EMPLOYER BILLING FORM (WORKERS’ COMPENSATION BOARD)(5 pages, 2008 version) $55
C4-2 Doctor’s Progress Report $55
NYS-45-ATT-MN (page 2 only) Quarterly Combined Withholding, Wage Reporting,And Unemployment Insurance Return – Attachment only (2nd page) see this link. 2006 version $37.99
NYS-45-ATT-MN Quarterly Combined Withholding, Wage Reporting,And Unemployment Insurance Return – 2 pages, 2005 version $84
AAP-33 New York State Department of Transportation Employment Utilization Report IN WORD $37.99
AAP-33 New York State Department of Transportation Employment Utilization Report IN EXCEL $75
CT-2658 Report of Estimated Tax for Corporate Partners; Description of Form CT-2658; Payments due April 15, June 15, September 15, 2010, and January 18, 2011& $37.99
CT-2658-ATT Attachment to Report of Estimated Tax for Corporate Partners; Description of Form CT-2658-ATT $37.99
CT-2658-E Certificate of Exemption from Partnership Estimated Tax Paid on Behalf of Corporate Partners& $37.99
IT-204 Partnership Return, Description of Form IT-204. The instructions are for partnerships completing Forms IT-204, IT-204-IP, IT-204.1, and IT-204-CP.&Updated information is available for this form; click here to see details& $37.99
IT-204.1 New York Corporate Partners’ Schedule K $37.99
IT-204-CP New York Corporate Partner’s Schedule K-1.& (The instructions are for the partner. Partnership instructions are in Form IT-204-I.)& $37.99
IT-204-IP New York Partner’s Schedule K-1.& (The instructions are for the partner. Partnership instructions are in Form IT-204-I.)& $37.99
IT-204-LL Partnership, Limited Liability Company, and Limited Liability Partnership Filing Fee Payment Form& $37.99
IT-370-PF Application for Automatic Extension of Time to File for Partnerships and Fiduciaries, Description of Form IT-370-PF.& $37.99
IT-2658 Report of Estimated Tax for Nonresident Individual Partners and Shareholders; Description of Form IT-2658; Payments due Payments due April 15, June 15, September 15, 2010, and January 18, 2011& $37.99
IT-2658-ATT Attachment to Report of Estimated Tax for Nonresident Individual Partners and Shareholders; Description of Form IT-2658-ATT; Payments due April 15, June 15, September 15, 2010, and January 18, 2011& $37.99
IT-2658-E Certificate of Exemption from Partnership or New York S Corporation Estimated Tax Paid on Behalf of Nonresident Individual Partners and Shareholders& $37.99
IT-2659 & Estimated Tax Penalties for Partnerships and New York S Corporations & $37.99
TR-2658 Revised Standards for Computer-Generated Form IT-2658-ATT and Form CT-2658-ATT& $37.99
Y-204 Yonkers Nonresident Partner Allocation $37.99
NY ET-706 New York State Estate Tax Return (4 pages) $12.99

State of New York Workers’ Compensation Forms in Word

Form No. Form Title Price Buy Now

A-9 (1/07)A-9S (Spanish version) on reverse Notice that You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim is Disallowed, or if Agreement Pursuant to WCL §32 is Approved $12.99
ADR-1 (1/11) Alternative Dispute Resolution Program Report of Injury $12.99
ADR-1.1 (1/11) Alternative Dispute Resolution Program: Modification of Previous Report $12.99
ADR-2 (1/11) Alternative Dispute Resolution Program Final Disposition or Settlement of Claim $12.99
AFF-1 (1-11) Affidavit For Death Benefits $12.99
BP-1 (12/08) Affidavit of Exemption to Show Specific Proof of Workers’ Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence $12.99
C-2 (1/11)& Employer’s Report of Work-Related Injury/Illness $12.99
CLAIMANT INFORMATION PACKET(which includes the two sided document, a C-3 form and C-3.3 form) CLAIMANT INFORMATION PACKET(which includes the two sided document, a C-3 form and C-3.3 form) $12.99
C-3 (1/11)& Employee Claim $12.99
C-3S (1/11) Reclamación del Empleado $12.99
C-3.1 (3/04)C-3.1S (Spanish version) on reverse Notice of Right to Select a Workers’ Compensation Board Authorized Health Care Provider $12.99
C-3.3 (12/09) Limited Release of Health Information (HIPAA) $12.99
C-4 (1/11) Doctor’s Initial Report $12.99
C-4.1 (9/08) Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4 $12.99
C-4.2 (1/11) Doctor’s Progress Report $12.99
C-4.3 (1/11) Doctor’s Report of MMI/Permanent Impairment $12.99
C-4 AMR (1/11) Ancillary Medical Report $12.99
C-4 AUTH (1/11) Attending Doctor’s Request for Authorization and Carrier’s Response $12.99
EC-4NARR (12/10) Doctor’s Narrative Report $12.99
C-5 (1/11) Attending Ophthalmologist’s Report $12.99
C-7 (1/11)& Notice That Right to Compensation is Controverted $12.99
C-8/8.6 (1/11)& Notice That Payment of Compensation Has Been Stopped or Modified $12.99
C-8.1 (1/11)& Notice of Treatment Issue/Disputed Bill $12.99
C-8.4 (1/11) Notice to Health Care Provider and Injured Worker of a Carrier’s Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s) $12.99
C-11 (1/11)& Employer’s Report of Injured Employee’s Change in Status or Return to Work $12.99
C-21 (1/11) Application for Advance on Periodic Payments of Compensation $12.99
C-22 (1/11) Application for Approval of Non-Schedule Adjustment $12.99
C-25 (1/11) Application for Reopening of Claim, More Than Seven Years After Accident $12.99
C-27 (1/11) Medical Proof of Change in Condition in Support of Application for Reopening $12.99
C-32 (11/09) Settlement Agreement,Section 32 $12.99
C-32.1 (1/11) Section 32 Settlement Agreement: Claimant Release $12.99
C-34 (7/09) Notice to Show Proof of Compliance with the Workers’ Compensation Law $12.99
C-62 (1/11) Claim for Compensation in Death Case $12.99
C-64 (1/11) Proof of Death by Physician Last in Attendance on Deceased $12.99
C-65 (1/11) Proof of Burial and Funeral Expenses by Undertaker $12.99
C-72.1 (1/12) Record of Percentage Hearing Loss $12.99
C-89.3 (11/01)(obsolete) Replaced by Form RFA-1 (for claimants/claimants’ representatives) OR RFA-2 (for carriers/Board-approved self-insurers) $12.99
C-105 (1/11) Notice of Compliance & Workers’ Compensation Law $12.99
C-105.1 Notice to Be Posted by Employers Under WCL for Automotive or Horse&Drawn Vehicles $12.99
C-105.10 (9-05) Gummed Label for Use with Form C-105 Upon Renewal of Policy $12.99
C-105.11 (11-10) Consent to NYS Workers’ Compensation Board Jurisdiction for non-New York Licensed Carriers (3C Coverage) $12.99
C-105.31 (1/04) Notice of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL $12.99
C-105.32 (4/04) Notice of Election of a Partnership, Limited Liability Partnership, Professional Limited Liability Partnership, Limited Liability Company, Professional Limited Liability Company or Sole Proprietorship to Bring Partners, Members or Self-Employed Persons Under the Coverage of the New York State Workers’ Compensation Law $12.99
C-105.41 (1/04) Revocation of Election of a Municipal Corporation or other Political Subdivision of the State to Bring Executive Officers Under Coverage of WCL $12.99
C-105.51 (1/04) Notice of Election to Exclude the Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage $12.99
C-105.52 (1/04) Notice of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage $12.99
C-105.53 (1/04) Revocation of Election of a Not-for-Profit Corporation or Unincorporated Association to Exclude an Unsalaried Executive Officer from Coverage $12.99
C-105.54 (3/99) Notice of Election to Bring Sheltered Workshop Participants Under Coverage of WCL $12.99
C-105.55 (1/04) Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage $12.99
C-107 Employer’s Request for Reimbursement (NY State Insurance Fund)Link to External Website $12.99
C-121 (1/11) Claim for Compensation and Notice of Commencement of Third Party Action $12.99
C-240 (1/11)& Employer’s Statement of Wage Earnings Preceding Date of Accident $12.99
C-250 (3/07) Notice of Claim for Reimbursement Out of Special Disability Fund Under Section 15-8 $12.99
C-251 (11/01)Form must be printed on yellow paper. Carrier’s Request for Reimbursement of Compensation Payments Under Section 15-8 $12.99
C-251.1 (11/01)Form must be printed on pink paper Carrier’s Request for Reimbursement of Medical Expenses Under Section 15-8 $12.99
C-251.2 (11/01)Form must be printed on blue paper Carrier’s Request for Reimbursement of Compensation Payments Under Section 14(6) Concurrent Employment $12.99
C-251.3 (1/11) Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) and Section 15(8) $12.99
C-257 (9/10) Claimant’s Record of Medical and Travel Expenses and Request for Reimbursement $12.99
C-258 (8/10) Claimant’s Record of Job Search Efforts/Contacts $12.99
C-300.34 (10/97) Statement of Unresolved Issues (Special Part for Expedited Hearings) $12.99
C-300.5 (7/97) Stipulation $12.99
C-312.5 (12/10) Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only) $12.99
C-430S (1/11) Statement of Rights (WCL) $12.99
C-669 (1/11) Notice to Chair of Carrier’s Action on Claim for Benefits $12.99
C-DB-22 Employer’s Statement (for Form DB-450) (NY State Insurance Fund) $12.99
CB-11 (11/06) Claimant’s Guide to the Conciliation Process $12.99
CB-11S (1/07) Guia Para Reclamantes Sobre El Proceso De Conciliación $12.99
CE-200 APPLY (2/09) Paper application for the CE-200, Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability Benefits Coverage $12.99
DB-102 (7/09) Information for Employer Regarding Disability Benefits Law $12.99
DB-118 (7/09) Employer’s Statement for the Purpose of Terminating Status as a Covered Employer $12.99
DB-120 (1/11) Notice of Compliance – Disability Benefits Law $12.99
DB-125 (2/05) Employer Identification Card $12.99
DB-130 (5/02) Employee’s Statement of Exempt Status $12.99
DB-135 (8/03) Employer’s Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (No Employee Contribution) $12.99
DB-136 (8/03) Employer’s Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (Employee Contribution) $12.99
DB-155 (7/09) Compliance With Disability Benefits Law $12.99
DB-159.1 (2/03) Notice of Termination of Employer’s Participation in Self-Insured Association, Union or Trustees Plan $12.99
DB-212.3 (1/04) Notice of Election of a Corporation Which is Required to Have Disability Benefits Coverage for its Employees to Exclude the Sole Shareholder Officer or One of the Two or Both Shareholder Officers of the Corporation from Such Coverage $12.99
DB-212.5 (11/06) Notice of Election to Voluntarily Exclude Spouse from Coverage $12.99
DB-271S (1/11) Statement of Rights (DBL) $12.99
DB-300 (2/04) Notice of Proof of Claim for Disability Benefits of Unemployed Claimant $12.99
DB-450 (2/04) Notice and Proof of Claim for Disability Benefits $12.99
DB-451 (3/99) Notice of Total or Partial Rejection of Claim for Disability Benefits $12.99
DB-455 (3/99) Notice of Disability Benefits Payment $12.99
DB-470 (11/09) Preliminary/Final Claim for Reimbursement of Benefits Paid Under DBL $12.99
DB-791 (2/00) Tables of Permanent Contributions $12.99
DB-802 (4/04) Employer’s Application to Have Association, Union or Trustee Plan Accepted as Employer’s Plan $12.99
DB-840 (2/00) Carrier’s Designation of Authorized Representatives $12.99
DB-850 (3/02) Application for Acceptance of Insurance Form $12.99
DC-120 (1/11) Discharge or Discrimination Complaint $12.99
DD-1 (2/06) Direct Deposit of Benefit Authorization Form $12.99
DD-2 (9/05) Biannual Recertification to Entitlement to Benefits $12.99
DT-1 (3/12) Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider $12.99
FCE-4 (1/11) Practitioner’s Report of Functional Capacity Evaluation $12.99
HIMP-1(1/09) Health Insurer’s Request for Reimbursement $12.99
HIPAA-1 (12-03) Claimant’s Authorization to Disclose Health Information (Pursuant to HIPAA) $12.99
HP-1 (4/05) Health Provider’s Request for Decision on Unpaid Medical Bill(s) $12.99
HP-4 (4/05) Notice to Chair: Health Provider’s and Insurer’s Withdrawal of Request for Arbitration $12.99
HP-J1 (7-08) Provider’s Request for Judgment of Award (WCL 54-b) $12.99
IG-1 (5-08) Fraud Complaint $12.99
IG-2 (5-08) Employer Fraud Referral Form $12.99
IME-3 (1/11) Practitioner’s Report of Request for Information/Response to Request Regarding Independent Medical Examination $12.99
IME-4 (1/11) Practitioner’s Report of Independent Medical Examination $12.99
IME-5 (1/11) Claimant’s Notice of Independent Medical Examination $12.99
IME-7 (4/05) Statement of Registration (Sec. 13n -WCL) $12.99
MD-1 (1/11) Attending Doctor’s Request for Medical Authorization Determination $12.99
MD-3 (1/11) Carrier/Board-approved self-insured employer’s Objection to Attending Doctor’s Request for Medical Authorization Determination $12.99
MG-1 (1/11) Attending Doctor’s Request for Optional Prior Approval and Carrier’s/Employer’s Response $12.99
MG-1.1 (12/10) Continuation to Form MG-1, Attending Doctor’s Request for Optional Prior Approval $12.99
MG-2 (1/11) Attending Doctor’s Request for Approval of Variance and Carrier’s Response $12.99
MG-2.1 (12/10) Continuation to Form MG-2, Attending Doctor’s Request for Approval of Variance $12.99
MR/IME-1 (4/05) Health Provider’s Application for Authorization Under the Workers’ Compensation Law $12.99
MR-4 (1/11) Impartial Specialist’s Report of Medical Records Review $12.99
OC-110A (1/11) Claimant’s Authorization to Disclose Workers’ Compensation Records (WCL Section 110-a) $12.99
OC-110AS (1/11) AUTORIZACIÓN DE RECLAMANTE PARA PERMITIR ACCESO A EXPEDIENTES ANTE LA JUNTA $12.99
OC-110AORD (7-10) Request for Judicial Order & Access to Case Files $12.99
OC-400 (1/11) Notice of Retainer and Substitution $12.99
OC-400.1 (1/11) Attorney/ Representative’s Application for Fee $12.99
OC-400.5 (3/09) Attorney/ Representative’s Certification of Form C-3 or C-7 $12.99
OC-401.1R (2/12) Renewal Application for License to Appear on Behalf of Claimant $12.99
OC-403.1 (2/12) Initial Application to become a NYS Licensed TPA $12.99
OC-403.1R (2/12) Renewal Application for TPA License $12.99
OC-403.2 (2/12) Initial Application by Employee of Licensee $12.99
OC-403.2R (2/12) Renewal Application by Employee of Licensee $12.99
OC-403.3 (2/12) Stockholder of Corporation Applying for License (New and Renewal) $12.99
OC-406 (5/08) Notice of Retainer and Appearance on Behalf of Employer $12.99
OC-407 (3/97) Self-Insurer’s Representative’s Bond $12.99
OC-409 (2/12) Initial Application to take License Representative Exam $12.99
OC-923 (1/11) Important Information for Employers Operating in New York State $12.99
OT/PT-4 (1/11) Occupational/ Physical Therapist’s Report $12.99
PH-16.2 (2/11)& Pre-Hearing Conference Statement $12.99
PS-4 (1/11) Psychologist’s Report $12.99
R (8/05) Carrier’s Report on Rehabilitation $12.99
RB-89 (1/11) Cover Sheet – Application for Board Review $12.99
RB-89.1 (1/11) Cover Sheet – Rebuttal of Application for Board Review $12.99
RB-89.2 (1/11) Cover Sheet & Application for Reconsideration / Full Board Review $12.99
RB-89.3 (1/11) Cover Sheet & Rebuttal of Application for Reconsideration / Full Board Review $12.99
RFA-1W (1/11)& Request for Assistance by Injured Worker $12.99
RFA-1LC (5/11)& Request for Further Action by Legal Counsel $12.99
RFA-2 (5/11)& Request for Further Action by Carrier/Employer $12.99
SI-12 (5/09) Affidavit Certifying That Compensation Has Been Secured $12.99
VAW-1 (8/97) Notice to Liable Political Subdivision of Volunteer Ambulance Worker’s Injury or Death $12.99
VAW-2 (1/11)& Political Subdivision’s Report of Injury to Volunteer Ambulance Worker $12.99
VAW-3 (1/11) Volunteer Ambulance Worker’s Claim for Benefits $12.99
VAW-62 (1/11) Claim for Volunteer Ambulance Workers’ Benefits in a Death Case $12.99
VAW-105 (1/11) Notice of Compliance – Volunteer Ambulance Workers’ Law $12.99
VAW-501 (1-06) Volunteer Ambulance Workers’ Benefit Rates & Death Benefits $12.99
VDF-1 (1/12) Loss of Wage Earning Capacity Vocational Data Form $12.99
VF-1 (8/97) Notice to Political Subdivision of Volunteer Firefighter’s Injury or Death $12.99
  Political Subdivision’s Report of Injury to Volunteer Firefighter $12.99
VF-3 (1/11) Volunteer Firefighter’s Claim for Benefits $12.99
VF-62 (1/11) Claim for Volunteer Firefighter Benefits in a Death Case $12.99
VF-105 (1/11) Notice of Compliance – Volunteer Firefighters Benefit Law $12.99
VF-501 (10-06) Volunteer Firefighters’ Benefit Rates & Death Benefits $12.99
VF/VAW-10 (10-06) Carrier’s Request for Benefit Increase Reimbursement Under Sec. 51 VFBL/VAWBL $12.99
VF/VAW-11C(1/11) Volunteer’s Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV Per VFBL/VAWBL Section 11-c(1) $12.99
WTC-12 (1/11) Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL §162 $12.99
WTC-16 (7/07) Cover Sheet: List of Itemized Medical Bills for Temporary Payment by the World Trade Center Volunteer Fund in Controverted World Trade Center Case $12.99
WTCVol-3 (2/04) World Trade Center Volunteer’s Claim for Compensation $12.99
W-32R (3/11) WAMO Settlement Agreement-Section 32 $12.99