How to Fill Out New York Form C-258.1: Entries, Submission, Penalties

New York Form C-258.1, the Claimant’s Record of Independent Job Search Efforts, is filled out by logging each employer you contact on your own, one contact per block, with the date, the method you used, the employer’s name and address, the person you spoke with, the job you asked about, the response you got, and any electronic confirmation number from an online application. The Workers’ Compensation Board treats the completed form as evidence that you remain attached to the labor market, so the quality of your entries matters as much as the number of them.¹

What Goes in Each Block

Start at the top of the page and enter the time period the form covers. That tells the Workers’ Compensation Law Judge which weeks or months the contacts below relate to. Each page then gives you four identical blocks. One block, one employer contact. For each one, fill in:²

Date of contact. The day, month, and year you reached out.
Method of contact. In person, telephone, email, or online application.
Employer name and contact information. Company name and address, plus the name and phone number of the person you dealt with where applicable.
Electronic confirmation number. If you applied online and received a confirmation email or reference number, record it here.

Four contacts per page is not a cap. If you have more to record, print additional copies or add pages online.² Running out of room is a good sign, not a problem.

In-Person and Phone Contacts

For contacts made in person or by phone, the Board expects real detail. At a minimum, document the employer’s name and address, the name and telephone number of the person you spoke with, the type of job you asked about, and the employer’s response. A vague entry like “Walked into store, asked about jobs” is the kind of thing a carrier challenges at a hearing. “Spoke with Maria Gonzalez, assistant manager, at ABC Hardware, 123 Main St., Buffalo — asked about stock clerk position, told no openings but to check back in two weeks” gives the judge something concrete to evaluate.³

Written and Email Contacts

If you applied in writing or by email, keep copies of everything: the resume you submitted, any cover letter or inquiry email, and the completed application if there was one. Record the date sent, the type of job, the employer’s name and address, and any response you received. Those backup documents should travel with the form when you file it or bring it to a hearing.

Online Applications

Most job applications today happen through employer websites and online job boards, and clicking “Apply” does not create the same paper trail as walking into a business. The Board bridges that gap with the electronic confirmation number field. Employer career portals and sites like Indeed or LinkedIn often generate a confirmation when you submit. Save it and record the reference number on the form.²

When a site gives you nothing, take a screenshot showing the submission with the date visible. An online search that leaves no verifiable trail is one the Board cannot evaluate, so building your own evidence as you go is worth the few extra seconds.

Make Sure the Search Itself Holds Up

Form entries only help if the underlying search meets the standard. The Board requires “timely, diligent, and persistent” efforts to find work consistent with your medical restrictions.² No specific number of contacts per week is published, which leaves the Workers’ Compensation Law Judge wide discretion.

Three practical things follow from that. First, apply to jobs that fit your documented work restrictions; a stack of applications for jobs you clearly cannot do carries little weight. Second, keep the search steady over time rather than cramming it into the week before a hearing. Third, fill in the form as the contacts happen, not from memory later. The level of detail the Board expects, down to the name of the person you spoke with and a confirmation number for each online application, is hard to reconstruct after the fact.

When You Also Need Form C-258

Form C-258.1 is strictly for an independent job search: employers you contact on your own by phone, in person, email, or online application. If your entire effort is independent, this is the only form you need.³

Form C-258 covers the other recognized methods of labor market attachment: participation in a One-Stop Career Center, ACCES-VR vocational rehabilitation, a job-retraining program, or full-time enrollment at an accredited school. If you are using any of those services on top of searching independently, fill out both C-258 and C-258.1.⁴

How to Submit the Form

The form and your supporting documents (confirmation emails, copies of applications, resumes) should reach the Board before your scheduled hearing. You have three options:⁵

Email. Send documents to WCBClaimsFiling@wcb.ny.gov at least three days before your hearing. Use a separate email for each claimant, and put your WCB Case Number and name in the subject line. Accepted formats include PDF, DOC, DOCX, JPG, and TIFF, among others. The combined attachment size cannot exceed 150 megabytes. If you are submitting a fillable PDF, first print it to PDF using “Microsoft Print to PDF”; otherwise the Board’s scanning system may receive a blank form.
eCase upload. Registered eCase users can upload documents when their case is in “Hearing Set” status.
Mail. If you are not represented by an attorney, you can mail documents at least six days before the hearing to PO Box 5205, Binghamton, NY 13902-5205.⁴

If you have not submitted the form in advance, bring it with you to the hearing and the Workers’ Compensation Law Judge will collect it then.¹ Keep a personal copy of everything you send in.

What Inadequate Documentation Costs

If the judge finds your job search inadequate, or finds that you failed to document it properly, the result is a determination that you are not attached to the labor market. Benefits get stopped, either for a specific period or on an ongoing basis.³ A claimant found to have voluntarily withdrawn from the labor market loses entitlement to compensation unless they can show that their disability caused or contributed to the withdrawal.

This is where the gap between doing a job search and documenting one becomes real. Plenty of claimants are genuinely looking for work but treat the form as an afterthought, filling it in from memory the night before a hearing, leaving out employer addresses, or skipping confirmation numbers for online applications. The Board treats Forms C-258 and C-258.1 as evidence. Incomplete evidence, even when the underlying effort was real, can still produce a negative finding. Fill out the form as you go, and keep every scrap of supporting paperwork.

1
Workers’ Compensation Board. Workers’ Compensation Forms Injured Workers
2
Workers’ Compensation Board. Labor Market Attachment
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Workers’ Compensation Board. Subject Number 046-958 Claimant Record of Job Search Efforts Revised Board Form C-258 and New Board Form C-258.1
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Workers’ Compensation Board. Claimant’s Record of Job Search Efforts/Contacts (Form C-258)
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Workers’ Compensation Board. How To Submit Claims-Related Forms And Documents To WCB