Workers' Compensation Forms

Employee Accident Reporting

Employees use these forms to report an injury sustained at work to your employer.

• Quick Employee Injury Packets: This document contains all information and required forms for County employee injuries.
  • Employee Injury Packets

Other Employer Forms

• Employer's Statement of Wage Earnings (C-240) - Employers use this form to report employee wages to the Self-Insurance Department.
  • Employer's Statement of Wage Earnings (C-240) (PDF)
• Employer's Report of Injury Employee's Change in Employment Status Resulting From Injury (C-11) - Employers use this form to report employee work status.
  • Employer's Report of Injured Employees Change in Employment Status Resulting From Injury (C-11) (PDF)
• Employer's Request for Reimbursement: Employers use this form to request reimbursement of wages advanced.
  • Employer's Request for Reimbursement (PDF)
• Direct Deposit Form for injured workers receiving indemnity payments - injured workers complete this form to have payments deposited directly to the bank selected.
  • Direct Deposit Authorization Form

* Carrier name and address:
Warren County SIF
1340 State Route 9, Lake George NY 12845,
Carrier Code: W874754
This information applies to Workers Compensation forms