New York > Workers Compensation
Request For Further Action By Carrier-Employer RFA-2 - New York
| Request For Further Action By Carrier-Employer Form. This is a New York form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
State of New York WORKERS' COMPENSATION BOARD REQUEST FOR FURTHER ACTION BY CARRIER/EMPLOYER This form is submitted by 1. WCB CASE NO. carrier 2. self-insurer 3. CARRIER CODE 4. mm ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS DATE OF INJURY dd yy 5. DISTRICT OFFICE CARRIER CASE NO. W NAME Check if new address: ADDRESS TO WHICH NOTICES SHOULD BE SENT APT. NO. 6. CLAIMANT 7. EMPLOYER 8. CARRIER ATTY/REP ID NO. 9. ATTORNEY OR LICENSED REP. R 10. INSTRUCTIONS: The carrier/employer seeks Board action regarding the claim identified above for the following reasons (check all that apply). Please note that the required documentation identified below must be attached to the form and submitted to the Board or must be referenced in the space provided below** (by date, name or title of document, and form ID) if it is already in the Board's electronic file. This form must be mailed, faxed or e-mailed to the Workers' Compensation Board. (See mailing and e-mail filing addresses on reverse side.) A copy of this form and the attachments must be sent to the claimant and claimant's representative if one has been retained. A copy of this form and the attachments must also be sent to the health care provider if item a or b is checked. Compensation: a. Continuing payments directed by the Board should be suspended as of pursuant to 12 NYCRR 300.23(b). (medical or payroll documentation supporting suspension required) b. Continuing payments directed by the Board should be reduced to /wk as of pursuant to 12 NYCRR 300.23(b). (medical or payroll documentation supporting reduction required) c. Payments should be modified as claimant is working at full or reduced earnings as of . (payroll documentation supporting modification required) d. Payments should be suspended as of as claimant has voluntarily removed him/herself from or is no longer attached to the labor market. (documentation supporting suspension required) e. Payments should be suspended as of because of disqualification pursuant to WCL §114-a. (list of documents or evidence to be produced required) f. Payment of benefits should be transferred to Special Funds pursuant to WCL §25-a. (documentation of a claim for compensation/ treatment more than 7 years after the injury/death and 3 years from the last payment of compensation required) Medical Issues: g. Claimant's disability is now amenable to a facial award or schedule loss of use award. (medical documentation indicating permanency required) h. Claimant's disability is now amenable to a non-schedule award. (medical documentation indicating permanency required) i. Claimant has made an application to reopen a previously established claim seeking additional benefits, and pursuant to 12 NYCRR 300.22 the carrier contends (statement as to the carrier's position on the payment of further benefits required) j. Carrier requests transfer regarding Special Funds liability pursuant to WCL §25-a. Other: k. Parties have entered into a stipulation. (Form C-300.5 or written stipulation required) l. Parties have reached an agreement and seek a Proposed Conciliation Decision. (Form C-312.5 or proposed findings required) m. Claimant has discontinued or settled a lawsuit pertaining to the accident/injury of this claim. (documents indicating discontinuance, settlement, or closing statement required) n. Carrier has new or requested documentation regarding (documents required) Other. (Explain fully in space provided below.) **Document reference information (date, name/title, form ID): I certify that this request for Board action is based upon reasonable grounds, and that this form with attachment(s) has been provided to the opposing party(ies). I also certify that (check one box below): I have discussed the issue(s) above with the opposing party(ies) or its representative(s) (give name of person contacted) _____________________________________________________ on (date) ________________________ and that: (check one) no settlement of the issue(s) could be reached. settlement of the issue(s) was reached (documentation required). I attempted to contact (name) on (date) above, that I have waited a reasonable time for a response, but that no discussion was forthcoming. CERTIFIED BY (Please Print Name) WCB ID NO. mm DATE PREPARED dd yy AREA CODE to discuss the issue(s) TELEPHONE NUMBER RFA-2 (5-11) SEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO American LegalNet, Inc. www.FormsWorkFlow.com TO THE CARRIER/EMPLOYER This form may be filed by the insurance carrier or employer in a workers' compensation case when it wants the Workers' Compensation Board to take action in the case. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. A copy of this form and the attachments must also be sent to the claimant, and his/her representative, if any. ITEMS a and b replace Form C-22b. If item a or b is checked, a copy of this form and the attachments must also be filed with claimant's attending doctor. If you would like on-line access to the case, you can register for eCase using the registration instructions available on the Board website under the eCase link. Regarding Items a and b - Board Rule 12 NYCRR 300.23 This notice (items a and b) replaces Form C-22b for the purpose of notifying the Board of the carrier/employer's intention to reduce or suspend the claimant's payments in accordance with Board Rule 12 NYCRR 300.23. This notice may be filed in any case where there has been an award and a direction for continuation of payments and evidence is presented to support the suspension of payments or reduction in rate. The Board, upon receipt of this notice and attachments, may either schedule a WC LAW JUDGE HEARING on this issue within 20 days during any period in which regular hearings are scheduled, or refer the matter to the Administrative Review Division for a determination of whether a reopening is warranted. In the event that the Administrative Review Division directs that the case be reopened, a WC Law Judge Hearing will be scheduled in an expeditious manner. IF THE REQUIRED DOCUMENTATION IS NOT ATTACHED, THE CASE WILL NOT BE SCHEDULED FOR A HEARING. Cases at hearing points which do not have regularly scheduled hearings within 20 days may be scheduled at another hearing point. At the time a WC Law Judge hearing is held, either immediately after the Board's receipt of this notice and attachments or at the direction of the Administrative Review Division, the WC Law Judge will consider all avai
|
|||||||
