WORKERS' COMPENSATION FORMS




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


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.



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 POMCO Group, when required.  Please complete and return the form immediately to the POMCO Group – P.O. Box 325, 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) The POMCO Group. 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



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) POMCO Group 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 the POMCO Group at P.O. Box 325, Syracuse, NY 13206-0325, within 24 hours from a date an employee returns-to-work and keep a copy for your records.  POMCO Group’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"




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