New York Form WCB C-300.5, titled Proposed Conciliation Agreement / Stipulation, is the official Workers’ Compensation Board document that the parties to a New York workers’ compensation claim sign to settle one or more disputed issues without a full hearing. It is filed with the New York State Workers’ Compensation Board and, once approved by a Workers’ Compensation Law Judge (WCLJ) or conciliator under 12 NYCRR 300.5(b), it carries the same force as a Board decision.
The Board flagged in Subject Number bulletin updates that older versions of the C-300.5 stopped being accepted after July 7, 2025, and roughly 15% of stipulations are still rejected on first review for missing parties, mismatched WCB Case Numbers, or unsigned signature blocks. Getting the form right the first time saves weeks of delay on benefits, surgery authorizations, and indemnity payments.
- 📝 What Form C-300.5 actually does and when a stipulation is the right tool
- 📋 A pre-filing checklist of every record, ID number, and exhibit you need
- 🧭 A line-by-line walkthrough of every field, with example entries
- 👥 Three full filled-out scenarios with named claimants, carriers, and outcomes
- ⚠️ The most common rejection reasons, deadlines, and consequences for each
What the Form Is and Who Must File It
Form C-300.5 is the New York Workers’ Compensation Board’s Proposed Conciliation Agreement / Stipulation. The parties use it to write down the terms they have agreed to on contested issues such as average weekly wage, degree of disability, periods of lost time, apportionment between carriers, or scheduled loss of use. The form lives on the Board’s All Common Forms page and is governed by Workers’ Compensation Law §25 and §32 along with the conciliation regulations in 12 NYCRR Part 300.
The form is signed by the claimant, the claimant’s attorney or licensed representative (if any), and the workers’ compensation insurance carrier or self-insured employer. Under the Board’s stipulation rules, an out-of-hearing C-300.5 sent in for desk review is only available when the claimant is represented by counsel. A pro se claimant can still stipulate, but must do it on the record at a hearing in front of a WCLJ.
The C-300.5 is not the same as a Section 32 Waiver Agreement (Form C-32), which fully closes a claim for a lump sum. As clarified by attorneys discussing the form in r/WorkersComp, a C-300.5 resolves specific issues but does not permanently close indemnity or medical benefits.
A typical filer is the claimant’s attorney drafting the stipulation after a hallway negotiation with the carrier’s representative, but the claimant must personally read, understand, and sign it. The Board treats the signed C-300.5 as a contract and an evidentiary admission once a judge signs the approval block.
Before You Start: Documents and Information You Need
Before opening the latest revision of the C-300.5 from the Board’s Forms for Injured Workers page, gather every document below. A missing item is the leading cause of stipulation rejection at desk review.
- The WCB Case Number. Without the seven- or eight-digit case number from your Notice of Indexing, the Board cannot match the stipulation to the claim file, and it will be returned unfiled.
- The Carrier Case Number and Carrier ID (W-code). These appear on every Notice of Decision; mismatched IDs cause the carrier’s claims system to reject the resulting decision and delay payment.
- Date of Accident or Date of Disablement. The exact date drives the statute of limitations, the indemnity rate, and which medical guidelines apply.
- Average Weekly Wage (AWW). The agreed AWW determines every dollar of indemnity; if you list the wrong figure here it overrides the prior set rate.
- List of established and contested body sites. Every site that has been or is being established (e.g., low back, right knee, consequential depression) must be listed verbatim.
- Periods of lost time and prior payments made. You will need start and end dates of every awarded period and the total compensation already paid.
- Most recent medical reports and IME (C-4AUTH, C-4.3, IME-4). These support the percentage of disability or scheduled loss of use being stipulated.
- Names, NYS Bar numbers, and signatures of all parties. Every party with a notice of appearance in the claim must sign or the stipulation is void.
- Scheduled Loss of Use Stipulation Attachment, if applicable. When SLU is being agreed to, the SLU Attachment must be filled out and incorporated by reference.
- A current W-9 from the claimant. Carriers require this before cutting any award check resulting from the stipulation.
Where to Get the Form and How to Access It
Always pull the C-300.5 directly from the Board so you get the current revision. The official PDF lives on the WCB All Common Forms index and the injured worker forms page. The Board confirmed in its April 2025 GovDelivery bulletin that older versions stopped being accepted after July 7, 2025, and the current revision allows unlimited typed text in the terms of the agreement field.
Do not download the form from third-party form aggregators. The Board’s automated intake compares the form’s revision date in the footer; an outdated revision triggers automatic rejection even if every field is correct. Always confirm the revision date printed at the bottom of the PDF before you type a single character.
If you file electronically through OnBoard, you upload the completed PDF as a Stipulation document type. Paper filers print the PDF, sign in blue or black ink, and mail or hand-deliver to the appropriate WCB District Office. Attorneys can also submit through eCase by attaching the signed PDF to a Request for Action by Legal Counsel (RFA-1LC).
The form is a fillable PDF. Complete it in Adobe Acrobat or any compliant PDF editor, then print, sign, and scan. The Board does not accept handwritten edits over typed answers; if a number changes, reprint the page.
Step-by-Step: How to Fill Out Form C-300.5 Line by Line
The C-300.5 is organized into a header (case identification block), a body (the stipulated terms), and a signature/approval section. Each H3 below maps to a specific field on the current Board revision. Use the exact wording and box order printed on the official PDF.
Field 1: WCB Case Number
This box asks for the unique number the Board assigned to the claim when it was indexed. Type the number exactly as it appears on the Notice of Indexing or any prior Notice of Decision, with no spaces and no leading zeros that are not on the original notice. Example: Maria Lopez writes G2845671 in the WCB Case Number box.
If the claim has been consolidated with another case, list the lead case number and reference the consolidated number in the terms of the agreement field. A frequent mistake is using the carrier’s claim number here instead of the WCB number; the desk reviewer cannot locate the claim and the form is returned without action. A common misconception is that the WCB Case Number changes if the claim is reopened — it does not, the same number follows the claim for life.
Field 2: Carrier Case Number
This field captures the insurance carrier’s internal claim number. Pull it directly from the most recent C-8/8.6 or Notice of Decision and type it verbatim, including any letters, dashes, or leading zeros. Example: Travelers writes ABA1234567-001 for Maria’s claim.
If the claim has changed carriers due to coverage transfer, list the current carrier’s number, not the original. Entering an old carrier number sends approval notices to the wrong adjuster and delays payment by an average of two to three weeks. Filers sometimes believe this field is optional because it isn’t a Board-issued number — it is mandatory whenever the carrier is not self-insured.
Field 3: Carrier ID Number (W-Number)
Every authorized New York carrier has a W-code on the Board’s carrier index. Enter it as W followed by six digits. Example: Travelers Indemnity Company is W123456.
For self-insured employers, use the SI- or GSI- prefix exactly as listed in the Board’s database. A wrong W-code routes the eventual decision to a different carrier, which then rejects the obligation, forcing a corrective filing. Many filers assume the TPA’s code goes here; it does not — the carrier of record is the one with payment liability.
Field 4: Claimant Name
Enter the claimant’s full legal name — first, middle initial, last — as it appears on the original C-3 Employee Claim. Do not use nicknames or shortened forms. Example: Maria E. Lopez, not Mari Lopez.
If the claimant has legally changed their name since the claim was filed, list the current legal name and add a parenthetical with the prior name (e.g., Maria E. Lopez (formerly Maria E. Garcia)). Mismatches between this field and the Board’s claimant record trigger an identity verification hold. Some filers think the name has to match a state ID — it must match the claim file, which is what the Board cross-references.
Field 5: Claimant Address
Use the claimant’s current mailing address, including apartment or unit number, city, state, and ZIP+4 if known. Example: 142 Grand Concourse, Apt 3B, Bronx, NY 10451.
If the claimant uses a P.O. Box for safety reasons (domestic violence, restraining order), list the P.O. Box and check the address confidentiality indicator if your version of the form has one; otherwise note it in the terms field. A wrong address here means the claimant never receives the Board’s approval decision and the 30-day appeal clock runs without their knowledge. The misconception is that the carrier’s address on file controls — only the address typed on the C-300.5 receives Board mail for this stipulation.
Field 6: Date of Accident / Date of Disablement
Enter the date of the work accident in MM/DD/YYYY format, or for occupational disease cases, the date of disablement. Example: 03/14/2024.
For occupational disease claims (carpal tunnel, hearing loss, lung disease), use the date of disablement that has already been established by the Board, not the date the claimant first felt symptoms. Putting an unestablished date here can be read as an attempt to amend the claim by stipulation, and the WCLJ will return the form. Filers often confuse date of accident with date of first medical treatment — these are distinct, and the Board uses the accident date for statute of limitations under WCL §28.
Field 7: Employer Name and Address
Type the employer’s full legal name as it appeared on the date of injury, plus the worksite address, not the corporate headquarters. Example: Acme Construction Corp., 4400 Northern Blvd, Long Island City, NY 11101.
If the employer’s legal entity changed (merger, dissolution, sale), use the entity legally liable on the date of injury and add the successor entity in parentheses. The wrong employer name here can void the stipulation if a coverage dispute later arises. A common misconception is that listing the parent company is fine — coverage attaches to the named insured on the policy, which is usually the operating subsidiary.
Field 8: Established Sites of Injury
List every body site already established in the claim, using the Board’s standard anatomical terms (e.g., low back, cervical spine, right shoulder, left knee, consequential depression). Example: Marcus Johnson’s stipulation lists low back, right knee, and consequential adjustment disorder.
If a site is being newly established by the stipulation itself, label it [New: site name] and address establishment explicitly in the terms field, because a stipulation can establish a site only if all parties agree on the record. Omitting an established site here is the most common substantive mistake — it can be read as a withdrawal of that site and waive future medical for it. Filers often think they only need to list the primary site; the form requires all established sites.
Field 9: Periods of Disability and Rates
Enter each agreed period of lost time with start date, end date, weekly rate, and degree of disability. Example: 03/15/2024–06/30/2024 at $1,125.00/week, total; 07/01/2024–12/31/2024 at $750.00/week, marked.
For ongoing periods, use to date for the end date and identify the percentage of disability. The most common mistake is failing to state the degree (total, marked, moderate, mild) — the carrier’s payment system cannot calculate without it, and an award without a rate is unenforceable. People assume the prior set rate carries over automatically; it does not — every period in the stipulation must restate the rate.
Field 10: Average Weekly Wage
Enter the agreed AWW to two decimal places. Example: $1,687.50.
If AWW is being amended by the stipulation, write Amended AWW: $X,XXX.XX (prior AWW $Y,YYY.YY) and reference the wage statements supporting the change. A frequent mistake is rounding to whole dollars — the Board’s calculation engine uses the cents and a mismatch flags the file. Some filers believe the AWW here only governs going forward; in fact it can retroactively recalculate every prior award unless the stipulation states otherwise.
Field 11: Scheduled Loss of Use (SLU), if applicable
If the stipulation includes an SLU, enter the body part, percentage, and number of weeks. Example: Right hand, 25% SLU, 61 weeks (244 weeks × 25%).
When SLU is involved, attach the Scheduled Loss of Use Stipulation Attachment and check the box incorporating it by reference. Forgetting the attachment is an automatic kick-back from desk review. A misconception is that SLU and a non-schedule permanency finding can be stipulated in the same C-300.5 — they generally cannot; non-schedule permanency uses different procedural rules.
Field 12: Apportionment
If liability is apportioned between carriers or between this claim and a prior claim, state the percentages and the WCB Case Numbers of the related claims. Example: 60% to G2845671 (Travelers); 40% to G1985432 (Hartford).
If there is no apportionment, write None — leaving it blank is read as ambiguous. Mistakes here ripple into every future award because the carriers split each check based on this field. Filers sometimes think apportionment is purely a carrier-side issue; it isn’t — the claimant must agree because it can affect attorney fees and lien recoveries.
Field 13: Terms of the Agreement (Free-Text Field)
This is the heart of the stipulation. Type the agreed terms in plain English, numbered paragraphs, covering every issue resolved. The Board’s April 2025 update made this field unlimited in length, so do not abbreviate.
Example terms paragraph: “1. The parties agree the claimant has a 25% Schedule Loss of Use of the right hand, equating to 61 weeks of compensation at $1,125.00/week. 2. The carrier shall pay the SLU award less prior payments of $14,625.00 within 30 days of Board approval. 3. The claimant’s counsel fee of 15% is approved on the unpaid balance.”
Address establishment, AWW, periods, rate, SLU, future medical, counsel fee, and any liens. The most common mistake is silence on future medical, which leaves the door open to disputes; always state whether future medical remains open. People often believe a brief one-line agreement is enough — the WCLJ will reject anything that doesn’t address every contested issue identified in the file.
Field 14: Counsel Fee
State the counsel fee amount or percentage being requested. Example: $5,000 fee, payable from the SLU award, pursuant to WCL §24.
The fee must be reasonable in light of the work performed, and the WCLJ has discretion to reduce it. Failing to request a fee in the C-300.5 means the attorney must file a separate OC-400.1, doubling the paperwork. A misconception is that the fee can come out of future indemnity — Board policy limits the fee to the additional benefit obtained by the stipulation, not future periodic payments.
Field 15: Claimant’s Signature and Date
The claimant signs in blue or black ink and dates the signature in MM/DD/YYYY. Example: /s/ Maria E. Lopez, 04/22/2026.
If the claimant cannot physically sign, an attorney-in-fact under a recorded power of attorney can sign and must attach the POA. Unsigned forms are returned the same day they are received. Filers often assume an electronic signature is fine — the Board’s current PDF accepts digital signatures with a verified certificate, but a typed name without a certificate is treated as unsigned.
Field 16: Claimant’s Attorney Signature, Bar Number, and Date
The attorney signs, prints name, lists NYS Bar registration number, and dates. Example: /s/ John A. Quinn, Esq., NYS Bar No. 4567890, 04/22/2026.
If the claimant is pro se, this block is left blank and the desk-review path is unavailable — the stipulation must be placed on the record at a hearing. Forgetting the Bar number is a common cause of the form being returned. The misconception is that any attorney listed in the file can sign — only the attorney with an active Notice of Appearance (Form OC-400) can.
Field 17: Carrier/Employer Representative Signature, Title, and Date
The carrier’s licensed representative or claims professional signs, prints title, and dates. Example: /s/ Susan Park, Senior Claims Examiner, Travelers Indemnity Co., 04/22/2026.
Self-insured employers sign through their authorized representative or TPA holding a valid power of attorney on file with the Board. A signature from someone without authority voids the stipulation. Some filers think the adjuster’s email approval is enough — the Board requires an actual signature on the PDF.
Field 18: WCLJ / Conciliator Approval Block
This block is left blank by the parties. The Workers’ Compensation Law Judge or conciliator signs and dates here once the stipulation is approved at a hearing or via desk review under 12 NYCRR 300.5(b).
Trying to fill this block in advance — even with the judge’s name typed — causes immediate rejection. The approval block is the moment the stipulation becomes a Board decision, and only the Board can complete it. A misconception is that the judge’s signature finalizes the agreement instantly; in reality the Notice of Decision that follows starts the 30-day appeal clock under WCL §23.
Three Filled-Out Examples Using Real Scenarios
Scenario 1: Maria Lopez — Home Health Aide With Right Hand SLU
Maria, a 42-year-old home health aide, suffered a crush injury to her right hand on 03/14/2024. After permanency exams, her treating physician found 30% SLU and the IME found 20%. The parties stipulate to 25% SLU.
| Form Section | What Maria Enters |
|---|---|
| WCB Case Number | G2845671 |
| Carrier Case Number | ABA1234567-001 |
| Carrier ID (W-Number) | W123456 (Travelers) |
| Claimant Name and Address | Maria E. Lopez, 142 Grand Concourse, Apt 3B, Bronx, NY 10451 |
| Date of Accident | 03/14/2024 |
| Established Sites | Right hand, right wrist |
| AWW and Rate | $1,687.50 AWW; $1,125.00 max rate |
| SLU Stipulated | 25% right hand = 61 weeks |
| Terms | 25% SLU; carrier pays award less prior $14,625 within 30 days; future causally related medical remains open; 15% counsel fee |
| Signatures | Maria, Atty. John A. Quinn (Bar #4567890), Susan Park for Travelers, all dated 04/22/2026 |
Scenario 2: Marcus Johnson — Construction Worker With Multi-Site Injury
Marcus, a 48-year-old ironworker, fell from scaffolding on 06/02/2023, injuring his low back, right knee, and developing consequential depression. The parties stipulate to AWW, periods of total and marked disability, and leave permanency open.
| Form Section | What Marcus Enters |
|---|---|
| WCB Case Number | G3104785 |
| Carrier Case Number | NYSIF-2023-0876543 |
| Carrier ID (W-Number) | W930000 (NYSIF) |
| Claimant Name and Address | Marcus T. Johnson, 88 Adams Street, Albany, NY 12202 |
| Date of Accident | 06/02/2023 |
| Established Sites | Low back, right knee, consequential adjustment disorder |
| Periods and Rates | 06/03/2023–12/31/2023 total at $1,145.43/wk; 01/01/2024–to date marked at $763.62/wk |
| AWW | $1,718.15 |
| Terms | AWW set at $1,718.15; periods and rates as stated; permanency reserved; future medical remains open; counsel fee $4,500 |
| Signatures | Marcus, Atty. Lisa Chen (Bar #5123987), NYSIF rep David Reilly, all dated 02/12/2026 |
Scenario 3: Aisha Williams — Office Worker With Carpal Tunnel Apportioned Between Two Claims
Aisha, a 55-year-old paralegal, has carpal tunnel syndrome stemming from two consecutive employers. The parties apportion liability 70/30 between two claims and stipulate to 15% SLU each hand.
| Form Section | What Aisha Enters |
|---|---|
| WCB Case Number | G2998112 (lead case) |
| Related Case for Apportionment | G2701889 |
| Carrier ID (W-Number) | W245678 (Hartford) / W198765 (Liberty Mutual) |
| Claimant Name and Address | Aisha M. Williams, 55 Elmwood Ave, Buffalo, NY 14201 |
| Date of Disablement | 09/15/2024 |
| Established Sites | Bilateral carpal tunnel (right and left hands) |
| SLU Stipulated | 15% right hand (36.6 wks) and 15% left hand (36.6 wks) |
| Apportionment | 70% Hartford (G2998112); 30% Liberty Mutual (G2701889) |
| Terms | Bilateral 15% SLU; apportionment 70/30; each carrier pays its share within 30 days; counsel fee 15% of unpaid SLU; future medical open both claims |
| Signatures | Aisha, Atty. Michael Torres (Bar #4998123), Hartford rep, Liberty rep, all dated 05/05/2026 |
How to File the Completed Form
The C-300.5 can be filed three ways once it is signed by all parties. Each channel has its own address, fee, and processing time, and you should keep proof of delivery for every channel.
By mail: Send the original signed PDF to the appropriate WCB District Office with jurisdiction over the claim. There is no filing fee. Use USPS Certified Mail with Return Receipt or a tracked carrier (FedEx, UPS) to preserve proof of mailing. Expect 30 to 60 days for desk review or assignment to a hearing.
By fax to the assigned District Office: The Board accepts faxed stipulations at the District Office fax line listed for your case. There is no fee. Keep the fax confirmation page; without it, you cannot prove timely filing if the form is lost. Processing time mirrors mail.
Through OnBoard / eCase: Represented parties upload the signed PDF to OnBoard as a stipulation document and link it to the case number. There is no fee. Electronic filings are date-stamped instantly, and eCase generates a confirmation receipt to download and save. Processing is the fastest, often 14 to 30 days for desk review under 12 NYCRR 300.5(b).
In person: hand-deliver to the District Office front desk and ask for a date-stamped copy as proof. Whichever channel you choose, save a complete copy of the signed PDF and every attachment for the claim file — once the WCLJ approves, the only proof of the original terms is your saved copy.
What Happens After You File
Once the Board receives the C-300.5, intake routes it to either desk review (when claimant is represented and the issues qualify) or to the next available hearing calendar. A WCLJ or conciliator reads the terms, checks them against the file, and either approves, modifies with consent, or rejects.
If approved, the Board issues a Notice of Decision memorializing the stipulation. The 30-day appeal window under WCL §23 starts on the filing date of that decision. The carrier must pay any award triggered by the stipulation within the period stated in the agreement, typically 30 days; failure to pay timely accrues a 20% penalty under WCL §25(3)(f).
If rejected, the Board issues a notice listing the reasons, and the parties can revise and resubmit or convert the matter to a hearing. Common rejection reasons include missing signatures, mismatched case numbers, unaddressed contested issues, or terms that conflict with established medical evidence. The claimant retains the right to withdraw consent at any time before the WCLJ signs the approval block.
Mistakes to Avoid When Filling Out the Form
- Using an outdated revision. Older versions stopped being accepted after July 7, 2025, and trigger automatic rejection per the Board’s bulletin.
- Leaving the WCB Case Number blank or wrong. The Board cannot index the stipulation to the claim, and the form is returned unfiled.
- Mixing up Carrier Case Number and W-Number. The decision routes to the wrong adjuster, delaying payment by weeks.
- Misstating the date of accident. Even a one-day error can implicate statute of limitations defenses under WCL §28.
- Forgetting an established body site. Omission can be construed as withdrawal, waiving future medical for that site.
- Skipping the rate or degree of disability. The carrier’s payment system cannot calculate, and the award is unenforceable.
- Using the wrong AWW. The AWW on the form overrides the prior set rate and recalculates everything if not properly worded.
- Forgetting to attach the SLU Stipulation Attachment. Required whenever SLU is part of the deal; missing it is auto-reject.
- Filing without all signatures. Every party with a Notice of Appearance must sign in ink or with a verified e-signature.
- Filling in the WCLJ approval block. Only the judge or conciliator signs there; pre-filled approval blocks are rejected.
- Silence on future medical. Always state whether causally related future medical remains open or is closed.
- Submitting pro se by desk review. Out-of-hearing review is only available to represented claimants.
Do’s and Don’ts
- Do download the C-300.5 directly from the WCB forms page so the revision date is current and the form passes intake.
- Do spell out every contested issue in numbered paragraphs in the terms field, because the WCLJ approves only what is written.
- Do match every name, number, and date to the existing claim file, since cross-checks drive automatic rejection.
- Do keep certified-mail receipts, fax confirmations, or eCase upload screenshots, because filing date governs the 30-day appeal window.
- Do address counsel fees in the form itself to avoid having to file a separate OC-400.1 fee request.
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Do confirm the carrier’s W-Number on the WCB Carrier Index before typing it.
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Don’t sign a C-300.5 before reading every term out loud with the claimant, because once approved it binds them.
- Don’t abbreviate body sites; the Board cross-references against ICD codes and standard anatomy.
- Don’t leave future medical silent; specify open or closed and any caps.
- Don’t rely on the carrier’s claim number alone; the Board uses the WCB Case Number to file.
- Don’t file by desk review without confirming the claimant is represented by counsel, per 12 NYCRR 300.5(b).
- Don’t assume an unsigned email confirmation from the adjuster equals a carrier signature.
Pros and Cons of Filing on Your Own vs. With Help
| Approach | What It Looks Like |
|---|---|
| Pro: Filing with an attorney | Counsel drafts the terms, ensures every site is captured, and routes to desk review for fastest approval. |
| Pro: Faster resolution | Stipulations approved by desk review under 12 NYCRR 300.5(b) often clear in 14–30 days versus months for hearing. |
| Pro: No filing fee | The Board charges nothing to file the C-300.5, regardless of channel. |
| Pro: Locks in agreed AWW and rate | Removes ambiguity for every future award on the claim. |
| Pro: Preserves future medical | Unlike a Section 32 Waiver, causally related medical can remain open. |
| Con: Pro se claimants cannot use desk review | Self-represented filers must place the stipulation on the record at a hearing. |
| Con: Drafting errors are binding | A vague terms paragraph can be enforced as written, even if it’s not what the claimant intended. |
| Con: 30-day appeal window is short | Errors discovered after approval require a quick RB-89 application to modify. |
| Con: Counsel fees reduce net recovery | A 15% fee on an SLU award is a real cost the claimant should weigh. |
| Con: Cannot reopen lightly | Although less final than Section 32, modifying a stipulated finding requires showing change of condition or fraud. |
FAQs
Is Form C-300.5 the same as a Section 32 Waiver Agreement?
No. A C-300.5 is a stipulation on specific issues; a Section 32 (Form C-32) is a full lump-sum waiver that closes the claim entirely.
Can a pro se claimant file a C-300.5 by mail?
No. Under 12 NYCRR 300.5(b), out-of-hearing desk review is only available when the claimant is represented; pro se stipulations must be placed on the record at a hearing.
What happens if I file an older version of the form?
No older revision is accepted after July 7, 2025, per the Board’s bulletin; the form is rejected at intake and you must refile on the current PDF.
Do I write the carrier’s claim number or the WCB number in Field 1?
No. Field 1 is the WCB Case Number from the Notice of Indexing; the carrier’s number goes in the separate Carrier Case Number field.
Should I list every body site or only the disputed ones?
Yes, list every established site verbatim, because omitting a site can be read as a waiver of future medical for it.
Do I need to fill in the WCLJ approval block before mailing?
No. That block is for the judge or conciliator only; pre-filling it triggers automatic rejection.
Is an electronic signature acceptable on the C-300.5?
Yes, a digital signature with a verified certificate is accepted; a typed name without a certificate is treated as unsigned.
Can the AWW on the form override the prior set rate?
Yes, the AWW typed in Field 10 controls going forward, and unless the terms say otherwise it can recalculate prior periods.
Is there a filing fee?
No, the New York Workers’ Compensation Board charges no fee to file the C-300.5 by mail, fax, in person, or through OnBoard.
How long does desk review take?
Yes, desk review typically clears in 14 to 30 days when the file is complete, compared with 60+ days for a hearing-calendar slot.
Can I withdraw consent after I sign?
Yes, either party can withdraw before the WCLJ signs the approval block; once signed, the 30-day appeal window under WCL §23 controls.
Do I attach medical reports to the C-300.5?
Yes, attach the IME, treating-doctor permanency report, or wage statements that support the stipulated findings, especially for SLU under the SLU Attachment.
Does the C-300.5 cover travel expenses or mileage reimbursement?
No. Mileage and medical expense reimbursement is requested on Form C-257 at the 2026 rate of 72.5 cents per mile, not on the C-300.5.
What if the claimant’s name changed after filing the C-3?
Yes, list the current legal name and add the prior name in parentheses so the Board’s claimant record cross-references match.
Can the stipulation establish a new body site?
Yes, but only if all parties expressly agree on the record and the medical evidence supports it; mark the site [New: …] and address it in the terms.
Related reading
- How to Fill Out New York Form C-4.3 (w/Examples) + FAQs
- How to Fill Out New York Form C-4 (w/Examples) + FAQs
- How to Fill Out New York Form WCB C-30 (w/Examples) + FAQs
- How to Fill Out New York Form WCB C-7 (w/Examples) + FAQs
- How to Fill Out New York Form WCB RB-89.1 (w/Examples) + FAQs
- How to Fill Out New York WCB Insurance Coverage Statement + FAQs
- How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs