New York > Workers Compensation
Cover Sheet-Application For Board Review RB-89 - New York
| Cover Sheet-Application For Board Review Form. This is a New York form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
STATE OF NEW YORK WORKERS' COMPENSATION BOARD DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 100 Broadway Menands ALBANY 12241 State Office Building 44 Hawley Street BINGHAMTON 13901 0DLQ 6WUHHW 6XLWH BUFFALO 1420 130 Main Street W. ROCHESTER 14614 935 James Street SYRACUSE 13203 COVER SHEET - APPLICATION FOR BOARD REVIEW WCB Case Number(s) Carrier Case Number(s) Carrier Code Carrier's Name Date of Injury Claimant's Name Address TO THE APPLICANT: This Application for Board Review may be filed with the Board by fax (1-877-533-0337; see Subject No. 046-144), e-mail (wcbclaimsfiling@wcb. state.ny.us; see Subject Nos. 046-144 and 046-375), personal delivery to a Board District Office, or by mailing to one of the Board addresses listed at the top of this page. A copy of this Application must be served on all parties in interest. Sections 1 and 2 on the reverse side of this form must be completed. The failure to supply all information requested by this form may result in dismissal of the Application. If an additional attorney fee is being requested, Form OC-400.1 must be attached and served on all parties. For Applications filed by a carrier, TPA or self-insured employer, an up-to-date Form C-8/8.6 must be attached and served on all parties. TO ALL OTHER PARTIES: Any Rebuttal to this Application must be served on the Board within 30 days following the date on which the Application was served on the parties, as specified in Section 2 on the reverse side of this form. 1. This application is made on behalf of: Claimant Employer/Carrier (name) Special Funds Uninsured Employers' Fund Attorney/Licensed Representative 2. This application is made for: (choose only one) Review of WCLJ Decision (WCL § 23 and 12 NYCRR 300.13) Rehearing or Reopening (12 NYCRR 300.14) 3. The filing date of the decision which is the subject of this application is: 4. The remedy sought is: Administrative Correction of Decision Reversal of the Decision 5. This application arises from an expedited hearing: 6. Specify the issue(s) for review: Employer/employee relationship Accident Occupational Disease Notice Causal Relationship Death Benefits Timely Claim Filing Jurisdiction Average Weekly Wage Authorization of Treatment Period of Disability Degree of Disability Reimbursement Penalty WCL § 114-a Disqualification Apportionment Special Funds Liability Attorney/Licensed Representative Fee Facial Award Section 32 Denial Disability Benefits Discrimination Policy Coverage ATF Deposit Yes No Modification of the Decision Rescission of the Decision 7. Specify the grounds for review (foundation, basis, or points) relied upon in raising the issues identified above. 8. Make reference to the record below, or such part thereof, as is relevant to the issue(s) and ground(s) raised in this application. Also, indicate when and where such issue(s) and ground(s) were raised before the Workers' Compensation Law Judge. Hearings (if minutes are not transcribed, so indicate): Documents: provide name and document ID number: RB-89 () THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com Transcripts: provide date and document ID number: Non-Scanable Evidence or Videotape (WMV or AVI format only): provide description: 9. List the following period(s) and/or medical benefits awarded which will be withheld pending this application: 10. A Form OC-400.1 for an increased attorney's fee that has been properly served has been included with this application for consideration by the Board. Yes No Certification: By signing this document in the space provided below, I certify that this application has a good faith basis in law and fact, has been instituted with reasonable grounds, and has been served upon all parties at the addresses listed in the affirmation or affidavit of service below. I understand that the Workers' Compensation Law provides for substantial penalties for instituting or continuing proceedings without reasonable grounds and/or for the purpose of delay. I understand that if this application is withdrawn for any reason or if any of the issues raised are resolved by the parties, I must immediately notify the Board and the parties served in writing. Signature of Person Preparing Form Print Name Address SECTION 1 AFFIRMATION Date ______/______/______ Title Phone Number (______)______________ STATE OF NEW YORK, COUNTY OF ________________ ss: I, the undersigned, am an attorney duly admitted to the practice of law in the courts of the state of New York. I hereby certify that I have complied with the filing and service requirements for this Application for Board Review in the manner described in Section 2 below. I affirm that the foregoing statements are true under penalties of perjury. Dated ______________________ Signature _______________________________________________________ Signer's Name (Print) ______________________________________________ __________________________________________________________________________________ AFFIDAVIT STATE OF NEW YORK, COUNTY OF ________________ ss: I, _______________________________________________________, being duly sworn, say: I am over 18 years of age. I hereby certify that I have complied with the filing and service requirements for this Application for Board Review in the manner described in Section 2 below. Sworn to before me on _________________ ____________________________________ Notary Public SECTION 2 A. Method by which Application was Filed with the Board (Check One): Fax (1-877-533-0337) E-Mail (wcbclaimsfiling@wcb.state.ny.us) Mail (specify date below) Personal Delivery (specify date below) Signature ___________________________________________________________ Signer's Name (Print) _________________________________________________ Date of Mailing: __________________________ B. Method of Service on the Parties (Check One): Date of Personal Delivery:____________________________ Mail Personal Delivery Specify Date of Mailing or Personal Delivery ____________________________ C. Names and addresses of all Parties Served: (Attach additional sheets if necessary.) RB-89 () Reverse American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
