How to Fill Out NY Workers’ Compensation Form C-240: Employer’s Wage Statement

To fill out New York Workers’ Compensation Form C-240, the Employer’s Statement of Wage Earnings, you report the injured worker’s gross pay and days worked for each of the 52 weeks before the injury, note any gaps in employment, certify the figures, and return the form to the Workers’ Compensation Board within 10 days of its request.¹² The figures you enter drive the Average Weekly Wage (AWW) calculation that controls every benefit payment on the claim, so accuracy matters as much as speed.

Where to Get the Form

You have two options. The WCB hosts an online version you can complete and submit directly through the Board’s web portal.³ You can also download the printable PDF from the Board’s forms page and submit it by mail, fax, email, or web upload.¹ The online form feeds straight into the Board’s system; the PDF is easier if you need to route the document for internal signatures before filing.

Identifying Information at the Top

Three blocks sit at the top of the form. The injured worker block takes the first name, last name, middle initial, mailing address, and Social Security number. The claim block takes the WCB Case number and the Claim Administrator (Carrier Case) number, both of which appear on any prior correspondence from the Board or the carrier. The employer block takes the business name and full mailing address.¹ Verify the case and carrier numbers against your claim file before you move on; every piece of Board correspondence on this claim keys off them.

The 52-Week Earnings Grid

The core of the form is a 52-row grid covering the 52 weekly periods immediately before the date of injury or illness.³ For each week you enter three things: the week-ending date, the number of days the employee worked, and the gross amount paid including overtime. Count the week-ending dates backward from the injury date. This is a common source of error when the injury falls mid-week.

Gross pay is everything: regular wages, overtime, bonuses, tips, and gratuities. The form specifically asks whether the worker’s compensation included board, rent, housing, tips, or gratuities on top of the weekly wage figure.¹ If any of those applied, answer “yes” and include the value. Omitting non-cash compensation understates actual earnings and can lead to a correction order from a Law Judge later.

The days-worked column deserves careful attention. A five-day worker and a six-day worker have their annual earnings calculated differently under Section 14 of the Workers’ Compensation Law: five-day workers use a 260-day multiplier, six-day workers use 300.⁴ A wrong day count shifts the AWW and, with it, every weekly check the worker receives.

Gaps in Employment and the “Same Class” Employee

If the injured worker did not work for substantially the whole year before the injury, use question 8 to note the gaps and explain the reason: seasonal work, a leave of absence, a recent hire date, and so on.⁵ The Board needs that context to pick the right calculation method under Section 14.

When the worker hasn’t been on the job long enough to generate a full 52-week history, page 2 of the form asks for payroll data on an “employee of the same class.” That means someone doing the same type of work at a similar pay rate who did work a substantial part of the preceding year.¹ The Board’s guideline for “substantial part of the year” is 234 days for a five-day worker and 270 days for a six-day worker.³ If no comparable worker meets that threshold, explain why in detail. For example: “the closest similar employee only worked 20 weeks.”⁵

Signing and Certifying the Form

The preparer must sign and certify that the information is “true and to the best of my knowledge and belief.” The form carries a prominent warning that anyone who knowingly makes a false statement or misrepresentation on a material fact is guilty of a crime and subject to substantial fines and imprisonment.¹ Under WCL Section 131, falsifying payroll records is a misdemeanor punishable by a fine of $5,000 to $10,000, and a second offense within ten years escalates to a class E felony with fines up to $25,000.⁶ Cross-check every figure against your internal payroll system and the worker’s W-2 before signing. Discrepancies between the C-240 and tax documents invite scrutiny and delay benefit payments.

How to Submit and By When

The Board accepts the completed form through any of five channels.⁷ Pick one:

Online web form on the Board’s website.
Web upload of the completed PDF through the WCB Web Upload Link on the Forms page.
Email to wcbclaimsfiling@wcb.ny.gov.
Mail to NYS Workers’ Compensation Board, PO Box 5205, Binghamton, NY 13902-5205.
Fax to (877) 533-0337.

Send a copy to the insurance carrier handling the claim as well. The filing deadline is 10 days from the Board’s request.² A missed deadline can draw a $50 penalty per instance without a warning first.⁸

Why the Numbers Matter

The entries on Form C-240 feed directly into the AWW formula under Section 14. The Board applies one of three methods depending on how long the worker held the job before the injury.⁴

If the worker was employed substantially the whole year, the Board computes the average daily wage and multiplies by 260 for a five-day worker or 300 for a six-day worker, then divides by 52.
If the worker was employed less than substantially the whole year, the Board uses the earnings of a same-class employee who did work substantially the whole year, applying the same 260 or 300 multiplier.
If neither method can reasonably be applied, the Board looks at the injured worker’s prior earnings and those of similarly situated employees to arrive at a figure that fairly represents annual earning capacity. Annual earnings under this method cannot be less than 200 times the average daily wage.

Weekly disability benefits are paid as a percentage of the AWW, typically two-thirds, subject to a statutory maximum. For injuries occurring between July 1, 2025, and June 30, 2026, that maximum weekly benefit is $1,222.42.⁹ A C-240 that understates earnings can push the worker’s benefit below what they are entitled to; an overstated form can trigger a carrier credit against future payments. Either way, the Board eventually reviews the wage data at a hearing, and a Workers’ Compensation Law Judge sets the official AWW on the record. The form you file is the first draft of that number, so get it right the first time.

1
New York Workers’ Compensation Board. Employer’s Statement of Wage Earnings
2
New York State Workers’ Compensation Board. Workers’ Compensation Board All Common Forms
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New York State Workers’ Compensation Board. Employer’s Statement Of Wage Earnings
4
New York State Senate. New York Workers Compensation Law 14 – Weekly Wages Basis of Compensation
5
New York State Insurance Fund. Completing the Workers’ Compensation Board Form C-240
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New York State Senate. New York Workers Compensation Law 131 – Payroll Records
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Workers’ Compensation Board. Subject Number 046-909 Form Submission Guidelines
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New York State Senate. New York Workers Compensation Law 25 – Compensation, How Payable
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New York State Workers’ Compensation Board. Schedule of Maximum Weekly Benefit