Workers' Compensation Plan

Forms

  1. Accident Report Form
  2. C-11 Form
  3. C-240 Form
  4. C-2F Form
  5. C-3 Form
  6. C-3.3 Form
  7. Claimant Information Packet
  8. Direct Deposit Form
  9. DT-1 Form
  10. Employer Reimbursement Form
  11. HIPAA Release Form
  12. Injured Worker Letter
  13. Receipt for Employee Information Packet
  14. Rx - First Fill Information Sheet
  15. Rx First Fill Card to present to pharmacy
  16. Statement of Rights
  17. User Guide Online Portal Reporting
  18. VAW3 - Form
  19. VDF-1 Form
  20. VF-3 Form

Insurance Certificates

  1. SI-12 - 2023 Certificate of NYS Workers Compensation Self-Insurance Coverage

Posting Notices

C-105

  1. C105 Town of Barrington
  2. C105 Town of Benton
  3. C105 Town of Italy
  4. C105 Town of Jerusalem
  5. C105 Town of Middlesex
  6. C105 Town of Milo
  7. C105 Town of Potter
  8. C105 Town of Starkey
  9. C105 Town of Torrey
  10. C105 Village of Dresden
  11. C105 Village of Dundee
  12. C105 Village of Penn Yan
  13. C105 Yates County
  14. C105 Yates County Soil and Water Conservation

VF-105

  1. VF105 Bellona Fire Department
  2. VF105 Benton Fire Department
  3. VF105 Branchport Keuka Park Fire Department
  4. VF105 Dresden Fire Department
  5. VF105 Dundee Fire Department
  6. VF105 Himrod Fire Department
  7. VF105 Middlesex Fire Department
  8. VF105 Penn Yan Fire Department
  9. VF105 Potter Fire Department

NCAComp, Inc. Client Online Portal User Guide

  1. Online Client Portal User Guide