xDNU – Claim Forms

Report of Work–Related Injury/Illness (Form C–2F)

Lovell claim representatives are available to assist you with filing a claim, call us at 212-709-8600. The C-2F form must be filed for all claims except Minor Medical.

• Form C–2F (Employer to Complete) (FILLABLE)
• Form C–2F Instructions

Claimant Information Packet

On all claims except Minor Medical, you must provide the claimant with an information packet, which shall include the claim forms and notices below. Please read the Instructions To Employer before proceeding.

• Notice to Injured Employee
• Notice to Injured Employee (Spanish)
• C–3 Form, C–3.3 Form and Pharmacy Benefits Notice (English) (FILLABLE)
• C–3S Form, C–3.3S Form and Pharmacy Benefits Notice (Spanish) (FILLABLE)

Other Claim Forms

Please find below the most commonly used additional claim forms. Lovell claim representatives are available to assist you with filing other claim forms, call us at 212-709-8600.

• C-11: Employer’s Report Of Injured Employee’s Change In Employment Status Resulting From Injury (FILLABLE) Must be filed when injured employee returns to duty after an accident, subsequently stops working or upon request of the carrier or Workers’ Compensation Board.

• C-107: Employer’s Request for Reimbursement (FILLABLE) Where an employer seeks reimbursement for wages paid to an employee who was absent due to a work injury, this form must be filed before an award is made by the Workers’ Compensation Board.

• C-240: Employer’s Statement Of Wage Earnings (FILLABLE) Should be filed for all claims with lost time from work exceeds one week or upon request of the carrier of Workers’ Compensation Board.

• Supervisors Report of Incident Not required, but Lovell Safety Management strongly urges all employers to complete this form.