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.
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 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.
- Direct Deposit Form for injured workers receiving indemnity payments - injured workers complete this form to have payments deposited directly to the bank selected.
* 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