New York > Workers Compensation
Notice Of Retainer And Appearance On Behalf Of Employer OC-406 - New York
| Notice Of Retainer And Appearance On Behalf Of Employer Form. This is a New York form and can be used in Workers Compensation . |
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TO CHAIR State of New York WORKERS COMPENSATION BOARD NOTICE OF RETAINER AND APPEARANCE ON BEHALF OF EMPLOYER Date of Accident:__________________________ WCB Case No.____________________________ Claimant Discrimination Case No. ____________________ vs. Disability Case No._________________________ No-Insurance Case *Employer Double Indemnity Case Please take notice that the employer named above hereby appears in the above matter, and that the undersigned attorney has been retained to represent said employer in regards to the above matter. All notices, decisions and other documents in the above case are to be sent to the undersigned attorney at the address indicated below. Date Signature of Attorney Printed Name of Attorney Office Address Office Telephone Number Please take notice that I have retained the above named attorney to represent and appear by and on behalf of the employer in all proceedings in regards to the above matter. Date______________________ _______________________________________________________________ Signature of Person Authorized to Sign on Behalf of Employer _______________________________________________________________ Printed Name of Person Authorized to Sign on Behalf of Employer _______________________________________________________________ Title of Person Authorized to Sign on Behalf of Employer This form is for use by employers and their attorneys ONLY. An attorney retained by an employers insurance carrier is not permitted to use this form. Both the attorney and the employer must sign this form. * In a No-Insurance Case the "Alleged Employer." OC-406 (12-03)
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