New York > Workers Compensation
Renewal Application By Employee Of Licensee Under Section 50 3-b Or 50 3-d To Appear Before WCB OC-403.2R - New York
| Renewal Application By Employee Of Licensee Under Section 50 3-b Or 50 3-d To Appear Before WCB Form. This is a New York form and can be used in Workers Compensation . |
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State of New York WORKERS' COMPENSATION BOARD RENEWAL APPLICATION BY EMPLOYEE OF LICENSEE UNDER SECTION 50 3-b or 50 3-d TO APPEAR BEFORE THE WORKERS' COMPENSATION BOARD If additional information is needed, call the Licensing Unit at (1-800)664-2379 or (518)402-1372. Licensee License No. Company/Individual:______________________________________________________________________ Business address:_______________________________________________________________________ The undersigned hereby applies to the Workers' Compensation Board for a renewal of permission to appear before the Board and WC Law Judges in connection with workers' compensation matters as an employee of the above-named organization/individual licensed under Section 50 3-b or 50 3-d of the Workers' Compensation Law. 1. Applicant's Name (first, middle, last):_______________________________________________________ 2. Residence Address:____________________________________________________________________ 3. Home Telephone No.: (___) ________________ 4. List all employment during past three years: (Indicate regular place of doing business. Give present business first.) From To Employer Business Address Salary 5. Business Telephone Number: (___)__________________ Fax Number: (___)_____________________ Since your last application for license under this section, has status changed in following areas: q No If Yes: q United States of America q Other____________________ 6. Citizenship: q Yes If naturalized, give date and place of naturalization___________________________________________ If permanent resident alien, give registration no. and date______________________________________ 7. Education: q Yes q No If Yes, college, university or technical schools attended: School Name and Address From To Degree OC-403.2R (2-12) American LegalNet, Inc. www.FormsWorkFlow.com 8. Have you been disbarred or had revoked for cause any license, certificate, permit or any other authorization to practice in any trade or profession? q Yes q No If Yes, give details:_______________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 9. Have you been convicted of a crime? q Yes q No If Yes, state when and give details:_____________ ___________________________________________________________________________________ ___________________________________________________________________________________ 10. Are there any criminal charges now pending against you? q Yes q No If yes, give details:_________ ___________________________________________________________________________________ ___________________________________________________________________________________ 11. Approximately how many claims have you handled before the Workers' Compensation Board (including WC Law Judge and Board Parts) during the last completed calendar year? _______________________ In the event I terminate my employment with this licensee, I shall immediately relinquish the identification card issued to me by the Secretary, Workers' Compensation Board. VERIFICATION State of New York ) ss: County of______________________) ______________________________________________, being duly sworn, deposes and says that I am the applicant; that I have duly read and signed the foregoing application; that all the matters contained herein are true, excepting as to such matters therein stated to be alleged on information and belief and those matters I believe to be true. In addition, I hereby authorize duly designated employees of the Workers' Compensation Board to make inquiry into and to obtain the release and disclosure of any information, document or record required to obtain verification of any statement made in this application. Signature of Authorized Employee Sworn to before me this ____________day of_______________________ Notary Public NOTARY'S STAMP I hereby certify that the above-named applicant is an employee of _________________________________, which organization/individual has applied or will apply for a license to represent self-insured employers under Section 50 3-b or 50 3-d of the Workers' Compensation Law. Signature of Qualifying Officer of Employer who signed application Form C-403.1R Date OC-403.2R (2-12) Reverse American LegalNet, Inc. www.FormsWorkFlow.com
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