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New York > Appellate Courts > Appellate Division > 3rd Department > Civil

Notice Of Appeal (Workers Compensation) - New York

Notice Of Appeal (Workers Compensation) Form. This is a New York form and can be used in Civil 3rd Department Appellate Division Appellate Courts .
 Fillable pdf Last Modified 4/1/2013
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NOTICE OF APPEAL TO APPELLATE DIVISION, THIRD DEPARTMENT FROM DECISION OF WORKERS' COMPENSATION BOARD STATE OF NEW YORK SUPREME COURT APPELLATE DIVISION THIRD DEPARTMENT In the Matter of the Claim for Compensation Under the Workers' Compensation Law made by , Claimant, -against, Employer, and Respondents. WORKERS' COMPENSATION BOARD, Respondent. , Insurance Carrier, NOTICE OF APPEAL WCB No. PLEASE TAKE NOTICE that the above-named Claimant (or Employer, Insurance Carrier) in this matter, hereby appeal(s) to the Appellate Division of the Supreme Court, Third Judicial Department, from the decision of the Workers' Compensation Board filed the Dated: day of , 20 , and from each and every part thereof. (Signature) (Print Name) (Address) (Telephone) TO: (name[s] and address[es] of attorney[s] for other party/parties) Note: The notice of appeal must also be filed in the office of the Secretary of the Workers' Compensation Board at 328 State Street, Schenectady, NY 12305. Revised: February 22, 2013 American LegalNet, Inc.
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