New York > Workers Compensation
Statement Of Registration (Section 13n-WCL) IME-7 - New York
| Statement Of Registration (Section 13n-WCL) 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 STATEMENT OF REGISTRATION Section 13-n, WCL for entities deriving income from independent medical examinations Pursuant to Section 13-n of the Workers Compensation Law, any entity which derives income from independent medical examinations performed in accordance with Sections 13-a (4), 13-k(3), 13-l(3) or 13-m(4), of the WCL, whether by employing or contracting with independent examiners to conduct such independent medical examinations or by acting as a referral service or otherwise facilitating such examinations, shall register with the chair by filing a statement of registration containing such information prescribed by the chair in regulation. See Section 13-n on reverse of this form. Instructions: Complete all items below and on reverse. Please print or type. Illegible forms will be returned. A registration fee of $250 payable to the Chair, Workers Compensation Board, must accompany each submission. Send completed statements to: Workers Compensation Board, Office of Health Provider Administration, 100 Broadway-Menands, Albany, NY 12241. In the event that your company has a change of name, officers, owners or partners after your initial registration, you must submit a new registration statement and fee within 30 days. You must also notify the Workers Compensation Board, Office of Health Provider Administration, of any changes of address or business locations. 1. Entity Name(s) as registered with Department of State______________________________________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ _____________________________________________________Federal Tax ID No(s).___________________________ 2. Name(s) under which entity conducts business____________________________________________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ 3. Address and Telephone Number of each business location__________________________________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ 4. Address(es) of entitys administrative offices______________________________________________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ 5. Name, Title, Address and Telephone Number of each of the entity organizations officers, owners or partners ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ (Attach additional sheet if necessary.) IME-7 (4-05) Continued on Reverse American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 6. Describe the services provided by the entity and its employees or independent contractors, including a description of the relationship between the entity and its owners, officers or partners and its employees or independent contractors: ________________________________________________________________________ __________________________ ________________________________________________________________________ __________________________ ________________________________________________________________________ __________________________ ________________________________________________________________________ __________________________ ________________________________________________________________________ __________________________ ________________________________________________________________________ __________________________ ________________________________________________________________________ __________________________ ________________________________________________________________________ __________________________ (Attach additional sheet if necessary.) Contact Person for Entity____________________________ Title_______________________Tel. No.______________ STATE OF NEW YORK AFFIRMATION ss.: } County of .............................. ........................................................................ ......................................, being duly sworn, depose(s) and say(s) that (s)he is the .................................................................... of ........................................................................ ............... the entity named in the foregoing statement of registration; that (s)he has read the same and know(s) the contents thereof; and that the same is true to his/her own knowledge. Deponent further says that the......................................................is a ................................................................... (name of entity) (type of business, e.g., corporation, partnership, PLLC) entity and deponent is an officer thereof, to-wit its ........................................................................ ......(deponents title). Deponent further says that the entit
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