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.
- Claimant Information Packet: Information for people who will be making a claim
- Employee Accident Report (C-3.0): Employees use this form to report an injury at work to your employer
- Limited Release of Health Information (C-3.3): Employees complete this form and turn in with the accident report form
- Medical Authorization: Employees complete this form and turn in with the accident report form
- Medical Authorization (PDF)
- Encounter Form Employees take this form with you to your medical provider.
- Encounter Form (PDF)
- Claimant's Record of Medical and Travel Expenses (C-257)
Employer Accident Reporting
Employers use these forms to report an employee injury sustained at work.
- Employers Report of Accident (C-2F) - Employers use this form to report employee injuries to the Self-Insurance Department.
- Employer's Statement of Wage Earnings (C-240) - Employers use this form to report employee wages to the Self-Insurance Department.
- 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 Request for Reimbursement: Employers use this form to request reimbursement of wages advanced.
* 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