EC-4NARR

NYS Workers' Compensation

EC-4NARR
Patient Information
Patient Name

First Name Last Name
Patient Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient's Date of Birth *

Month Day Year
Date of Injury *

Month Day Year
Job title on the date of injury *
Patient's usual work activities on the date of injury *
What body part was affected by the injury as determined by the Workers Comp Board? *
Is the patient working now? *

Yes No
Employer Information
Name of the employer at the time of injury? *
Employer Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Phone Number
Insurance Information
Insurance Carrier Name *
Insurance Carrier ID # (Begins with 'W') if known:
Insurance Carrier Address (Where medical claims should be sent) if known

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Adjustor Name
Adjuster Phone Number
Nurse Case Manager Name
Nurse Case Manager Phone Number
WCB Case# (Most often begins with a 'G'): *
Carrier Case #: *
Attorney Name or Name of Law Firm (if any):
Attorney Phone Number
Should be Empty:

NYS Workers' Compensation