Renewal Application For License To Appear On Behalf Of Or Represent Carriers And-Or Self-Insurers {OC-403.1R} | Pdf Fpdf Doc Docx | New York

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Renewal Application For License To Appear On Behalf Of Or Represent Carriers And-Or Self-Insurers {OC-403.1R} | Pdf Fpdf Doc Docx | New York

Renewal Application For License To Appear On Behalf Of Or Represent Carriers And-Or Self-Insurers {OC-403.1R}

This is a New York form that can be used for Workers Compensation.

Alternate TextLast updated: 8/3/2015

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STATE OF NEW YORK - WORKERS' COMPENSATION BOARD RENEWAL APPLICATION FOR LICENSE TO APPEAR ON BEHALF OF, OR REPRESENT, CARRIERS AND/OR SELF-INSURERS under Section 50 3-b or 50 3-d of the Workers' Compensation Law and Rules Application is made under (CHECK ONE): Section 50 3-b Section 50 3-d If application is made for renewal of a license on behalf of a corporation, separate forms must be filled out and submitted by the president/CEO, the secretary, and the treasurer. If application is made on behalf of a partnership, separate forms must be filled out and submitted by each partner. Applicant's failure to disclose fully and accurately any fact or information called for by any question may result in the denial of the application or, if license has been renewed before the discovery thereof, in the revocation of the license or authorization. 1. Name of applicant/organization: Type of organization: individual partnership corporation Yes other (specify) No If Yes, state other names: Since last application, has any other name been used? Business address: Business telephone number: Fax number: Does your company have other offices in New York State? Yes No If yes, attach list (include name of office manager and authorized employees at location, business address, telephone number and fax number) 1a. Type of claims to be administered: workers' compensation disability benefits both 2. Name and home addresses of individual, partners, or officers and directors of corporation: (attach list if more than three) Name Home Address Title 3. Attach list of principal stockholders (all those owning at least 20% of corporation's stock) and indicate percentag e of stock owned by each. Each principal stockholder must complete Form OC-403.3 to be submitted with application. See copy attached--photocopy if additional copies are needed. 4. The following named persons will appear before the Board on my/our behalf when authorized: I agree to advise the Board of any changes and to surrender authorization cards that become invalid. Attach completed Form OC-403.2 for each employee listed. 5. List all self-insureds and carriers represented by licensee within the last year: OC-403.1R (7-15) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL HISTORY OF INDIVIDUAL, PARTNER OR QUALIFYING OFFICER Name:_____________________________________________ Title:_______________________________ Social Security No.:____________________________ (See Privacy Notification on Page 4. If you have no Social Security Number, explain on Page 4.) 6. List all employment during past three years: (Give present business first.) From To Employer Business Address Salary Since your last application for license under this section, has status changed in following areas: 7. Citizenship: Yes No If Yes: United States of America If naturalized, give date and place of naturalization If permanent resident alien, give registration no. and date 8. Education: Yes No From To Degree Other If Yes, college, university or technical schools attended: School Name and Address 9. Have you been disbarred or had revoked for cause any license, certificate, permit or any other authorization No If Yes, give details: to practice in any trade or profession? Yes 10. Have you been convicted of a crime? Yes No If Yes, state when and give details: 11. Are there any criminal charges now pending against you? Yes No If yes, give details: 12. Do you have any arrangement with any health care providers in order to facilitate handling of workers' No If Yes, give details: compensation claims? Yes 13. Have you any arrangement at the present time with any self-insured employers and/or insurance companies to represent them in connection with workers' compensation or disability benefits claims? Yes No If Yes, give details, including a list of all clients in this category: OC-403.1R (7-15) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com I hereby authorize duly designated employees of the Workers' Compensation Board to make inquiry into and to obtain the release and disclosure of any information, document or record required to obtain verification of any statement made in this application; and I hereby agree that in the event the Board issues a license to me to represent self-insurers under Section 50 3-b or 50 3-d of the Workers' Compensation Law, I shall practice in accordance with the Law and Board Rules and Regulations established for licensed representatives. Name of Organization Signature and Title of Qualifying Officer Signature of Individual, Partner or Officer whose personal history is listed ) ss: County of_______________________ ) _____________________________________________, being duly sworn, deposes and says that I am the applicant; that I have duly read and signed the foregoing application; that all the matters contained herein matters I believe to be true. are true, excepting as to such matters therein stated to be alleged on information and belief and those Sworn to before me this ____________ day of________________ ________ Notary Public Signature of Individual, Partner or Officer State of New York TO BE COMPLETED BY THE QUALIFIED OFFICER OF CORPORATE APPLICANTS ONLY State of New York ) City of________________ _________ ) ss: County of______________________ ) AFFIX CORPORATE SEAL HERE On this ___________ day of ___________________________, before me personally came ____________ __________________________________ to me known, who, being by me duly sworn, did depose and say that (s)he resides at ___________________________________, that (s)he is the ____________________ ___________________ and qualified officer of __________________________________, the corporation described herein, and which executed the above application; that (s)he knows the seal of said corporation; that the seal affixed to said application is such corporate seal; that it was so affixed by order of the Board of Directors of said corporation; and that (s)he signed his/her name thereto by like order. NOTARY PUBLIC NOTARY'S STAMP OC-403.1R (7-15) Page 3 American LegalNet, Inc. www.FormsWorkFlow.com PRIVACY NOTIFICATION The authority to request personal information from you, including identifying numbers such as your Federal Social Security Number, and the authority to maintain such information, is found in Section 5 of the Tax Law. Disclosure of this information by you is mandatory. The principal purpose for which this information is collected is to enable the Department of Taxation and Fi

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