New York > Workers Compensation
Application For A Fee By Claimants Attorney Or Representative OC-400.1 - New York
| Application For A Fee By Claimants Attorney Or Representative Form. This is a New York form and can be used in Workers Compensation . |
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DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 100 Broadway State Office Building 295 Main Street Menands 44 Hawley Street 130 Main Street W. 935 James St. Suite 400 ALBANY 12241 BINGHAMTON 13901 BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203 (866) 750-5157 (866) 802-3604 (866) 211-0644 (866) 802-3730 (866) 211-0645 STATE OF NEW YORK WORKERS' COMPENSATIO N BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. APPLICATION FOR A FEE BY CLAIMANT'S ATTORNEY OR REPRESENTATIVE in accordance with Board Rule 12 NYCRR 300.17 This form may be used for any fee request; however, it is required for all requests exceeding $450 and when specifically directed by the Board. TO THE CLAIMANT: IF YOU DID NOT OR WILL NOT ATTEND THE HEARING/MEETING/CONFERENCE/ARBITRATION AT WHICH THIS FEE REQUEST IS SUBMITTED TO THE BOARD, SEE SECTION C ON REVERSE. WCB Case No. Representative's Identification Number, If Any Claimant's Name Date Retained Claimant's Social Security Number Amount of Fee Previously Received, If Any R- a I,__________________________________________, ttorney/representative, request a fee of $___________________ for the following services rendered in the above case. A. SERVICES RENDERED TO THE CLAIMANT List below the services rendered on behalf of the claimant, including the dates of such service and the time spent. Include any disbursements actually incurred. Date Description of Service Rendered Time Spent Date Nature of Disbursement Cost OC-400.1 (1-11) Continued on reverse www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com B. SUBSTITUTION OF ATTORNEY/REPRESENTATIVE 1. Has the claimant to your knowledge any other attorney or representative? Yes No If yes, have you served Notice of Substitution upon the former attorney or representative? List previous attorneys and/or representatives: Yes No Name______________________________________ Address_____________________________________________ Name_______________________________________Address_____________________________________________ 2. What arrangement have you entered into with the other attorneys or representatives who have preceded you? C. F EE REQUEST SUBMITTED WHEN CLAIMANT IS NOT PRESENT AT HEARING/MEETING/CONFERENCE/ARBITRATION TO THE ATTORNEY/REPRESENTATIVE Important: When the claimant is not present at the proceeding at which this fee is requested, the attorney or representative must complete the item below and immediately mail a copy of this Application for Fee to the claimant. When the attorney/representative knows in advance that the claimant will not be present, the claimant's copy may be mailed in advance. I affirm that a copy of this application was mailed or otherwise delivered to the claimant on_____________________. Date TO THE CLAIMANT: At the hearing/meeting/conference/arbitration on ______________________, I requested or will request a fee of $______________ for representing you. The Workers' Compensation Board will render a decision on my request 10 days after this fee application is mailed to you or on the date of the proceeding, whichever is later. The fee approved will be deducted from your award and paid directly to me by the insurance company or employer. If you object to the amount of the fee that is being requested, you may attend the Board proceeding and state your objection. If the proceeding has already been held and a fee awarded, you may appeal the decision by filing a written objection with the Board within 30 days of the date of the decision. A copy of the objection must be sent to your attorney/representative and all other parties in the case. In the Application for Review or in the Rebuttal to the Application for Review or in the Memorandum of Law dated __________________, I requested an additional attorney's fee of $______________for representing you. The Workers' Compensation Board Panel or Workers' Compensation Law Judge will address my fee request in a Memorandum of Decision or Reserve Decision. If the fee is approved, it will be deducted from your award and paid directly to me by the insurance company or employer. If you object to the amount of additional fee that is being requested, you may submit your objections in writing to the Board within 30 days of the date of Application for Review. A copy of the objection must be sent to your attorney/representative and all other parties in the case. CLAIMANT'S STATEMENT (OPTIONAL) I have reviewed this fee request with my attorney/representative and I have no objection to this request at this time. I understand that the fee, if approved, will be deducted from my award. Claimant's Signature __________________________________________________ Date___________________________ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. Signature of Attorney / Representative Date Submitted Address of Attorney / Representative Telephone No. Date Amount of Fee Approved W.C. Law Judge's / Conciliator's or Designated Employee's Initials American LegalNet, Inc. www.FormsWorkFlow.com OC-400.1 (1-11) Reverse
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