(On-the-Job Injury or Illness)
How to File a Claim
If you are injured on the job, you should complete the Board's form Employee Claim (C-3) as soon as possible to ensure your benefits are not delayed or interrupted. You must also notify your employer in writing of when, where and how you were injured or became ill.
There are several ways to file the Employee Claim (C-3) form.
- Complete the web version of the Employee Claim (C-3) form. Please Note: you must have Adobe Reader version 9 or greater installed on your computer to fill out and submit this form. If you use a browser other than IE (like Google Chrome or Firefox), or use a MAC computer, be sure to click on the relevant instructions before filling out the form or the form may fail to submit after you complete it. Call 1-866-396-8314, and someone from the Board will help you fill out the form. File a paper Employee Claim (C-3) form.
- You may obtain a paper Employee Claim (C-3) form by visiting any Customer Service Center or District Office ; by printing form Employee Claim (C-3) from this website; or by calling (877) 632-4996, and the Board will mail you one. If you submit a paper form, please mail the completed Employee Claim (C-3) form to the Centralized Mailing address.
You will be notified by mail of any action regarding your claim.
Remember: You must file a claim within two years of the accident or within two years after you knew or should have known that a contracted disease was due to the nature of your employment.
When a claimant has passed away at work or due to an existing work injury/illness, the Next of Kin should file a C-62 (with the appropriate documentation) to the Board. The form C-64 would need to be filed by the last treating physician
stating how the deceased death is causally related to work (or the previous work injury). The C-65 would be completed by the funeral Home.
- Q. What do I need to do if my spouse/parent/child/grandchild(ren)'s has passed away while collecting workers' comp benefits?
- A. Notify the Board and Insurance Carrier¹ immediately and submit (when available) a copy of the Death Certificate. Q. As a widow/widower, will his/her compensation benefits continue coming to me once they passed?
- A. In most cases benefits may stop. The widow/widower must file for a Workers' Compensation Death claim showing medical proof that the claimants death was related to the established work injury. If the death claim is found compensable, payments may resume retroactive back to the date of death. Q. What do I need to do if my spouse/parent/child/grandchild(ren)'s death was because of his/her work injury?
- A. File for a Workers' Compensation Death claim by completeing and filing a C-62 with the appropriate documentation. You will also need to file the C-64 and, If you have it, file medical evidence from the last treating physician stating how the death is causally related to the original work injury/illness. Q. What if my Child was killed at work and has no dependents; are there benefits payable for at least funeral expenses?
- A. Parents who were not dependent on the deceased would be eligible for a no-dependency award if there were no spouse, children, or other dependent family members. They would also be eligible for up to the maximum allowed under Workers' Compensation for funeral expenses paid. Q. Can I file for a Death Claim if my spouse settled his/her case on a section 32 and has since passed away due to the injury/illness?
- A. Yes, only if the persons death was related to the actual injury/illness. ( Please see under the Workers' section on how to file a Death claim).
¹ licensed insurance company, third party administrator or self insured employer.