New York > Workers Compensation
Renewal Application For License To Appear On Behalf Of Or Represent Carriers And-Or Self-Insurers OC-403.1R - New York
| Renewal Application For License To Appear On Behalf Of Or Represent Carriers And-Or Self-Insurers Form. This is a New York form and can be used in Workers Compensation . |
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Name of applicant/organization:__________________________________________________________ Type of organization: individual partnership corporation other (specify)________________ ___________________________________________________________________________________ Since last application, has any other name been used? Yes No If Yes, state other names: ___________________________________________________________________________________ Business address:____________________________________________________________________ Business telephone number:__________________________ Fax number:_______________________ Does your company have other offices in New York State? Yes No If yes, attach list (include name of office manager and authorized employees at location, business address, telephone number and fax number) 2. Name and home addresses of individual, partners, or officers and directors of corporation: (attach list if more than three) Name Home Address Title 3. Attach list of principal stockholders (all those owning at least 20% of corporation's stock) and indicate percentage of stock owned by each. Each principal stockholder must complete Form OC-403.3 to be submitted with application. See copy attached--photocopy if additional copies are needed. 4. The following named persons will appear before the Board on my/our behalf when authorized: I agree to advise the Board of any changes and to surrender authorization cards that become invalid. Attach completed Form OC-403.2 for each employee listed. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 5. List all self-insureds and carriers represented by licensee within the last year: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2&5 3DJH American LegalNet, Inc. www.FormsWorkFlow.com 3(5621$/ +,6725< 2) ,1',9,'8$/ 3$571(5 25 48$/,)<,1* 2)),&(5 Name:_____________________________________________ Title:_______________________________ Social Security No.:____________________________ (See Privacy Notification on Page 4. If you have no Social Security Number, explain on Page 4.) 6. List all employment during past three years: (Give present business first.) From To Employer Business Address Salary 6LQFH \RXU ODVW DSSOLFDWLRQ IRU OLFHQVH XQGHU WKLV VHFWLRQ KDV VWDWXV FKDQJHG LQ IROORZLQJ DUHDV Yes No If Yes: United States of America Other____________________ 7. Citizenship: If naturalized, give date and place of naturalization___________________________________________ If permanent resident alien, give registration no. and date______________________________________ 8. Education: Yes No From To Degree If Yes, college, university or technical schools attended: School Name and Address 9. Have you been disbarred or had revoked for cause any license, certificate, permit or any other authorization to practice in any trade or profession? Yes No If Yes, give details:_______________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Yes No If Yes, state when and give details:____________ 10. Have you been convicted of a crime? ___________________________________________________________________________________ BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 11. Are there any criminal charges now pending against you? Yes No If yes, give details:_________ ___________________________________________________________________________________ ___________________________________________________________________________________ 12. Do you have any arrangement with any health care providers in order to facilitate handling of workers' compensation claims? Yes No If Yes, give details:____________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 13. Have you any arrangement at the present time with any self-insured employers and/or insurance companies to represent them in connection with workers' compensation or disability benefits claims? Yes No If Yes, give details, including a list of all clients in this category:_____________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 2&5 3DJH American LegalNet, Inc. www.FormsWorkFlow.com 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; and I hereby agree that in the event the Board issues a license to me to represent self-insurers under Section 50 3-b or 50 3-d of the Workers' Compensation Law, I shall practice in accordance with the Law and Board Rule
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