Common Forms

For your convenience, we at the Steenberg Law Firm provided access to common forms used in a New York workers’ compensation case. Please note that these forms are in PDF format. You may need the latest version of Adobe Reader which is available as a free download from Adobe’s website.

If you have trouble opening a form:

• Download/save the form onto your computer
• Open Adobe Reader
• Open the saved file

If you have any questions about filling out these forms please call our office at 716-558-2000 as we are more than happy to provide assistance.

HIPAA Release Form

Job Search Logs

Mileage, Travel, Medication Reimbursement Request Form

WC and COVID Information Packet

OC-110-a Claimant Authorization to Disclose WC Records

VDF-1 Form

C-3 Employee Claim Form

C-4.3 Doctor’s Report of Permanent Impairment

OC-400 Attorney Retainer