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Forms for line of duty injuries

Most of the forms below are PDF files. If you encounter any problems viewing PDFs on your computer, you may need to install the free Adobe Reader software.

PLEASE NOTE: The “Application For Age 26 Young Adult Coverage” form is no longer required by the UFT Welfare Fund. Members wishing to add a dependent under age 26 to their Welfare Fund coverage at no cost should use the Welfare Fund’s online Update Your Information (Change of Status) form.

In order to reopen a claim more than seven years after an accident, this form must be filed immediately with the chair of the Workers' Compensation Board, together with the attending doctor's report (form C-27) if required, at the district office at which the case was closed.

Use this form to claim out-of-pocket expenses related to your injury or illness.

The employer is required to fill out this report within 10 days to notify the Workers’ Compensation Board of your work-related injury or illness. You should not participate in filling out this form. See the C-2: Employer's Report - Filing Procedure for further instructions.

This form allows health care providers who have treated your previous injuries to release information to your employer’s workers’ compensation insurer.

You must fill out this form to initiate your Workers’ Compensation claim. You should retain one copy, file a second with the Board, and provide a third to your legal representative.

Your doctor must fill out this form at regular intervals — usually every 4-6 weeks — during your convalescence. It is used to determine your level of benefits — so it is very important that your doctor fills it out carefully.

This form details the nature of your injuries. It should be turned in to your principal within 24 hours of your accident or illness.

This form details the nature of your injuries. It should be turned in to your principal within 24 hours of your accident or illness.