State of New York WORKERS' COMPENSATION BOARD LICENSED REPRESENTATIVE’S DISCLOSURE OF CONFLICT OF INTEREST TO CLIENT (Section 24a, 50 3-b and 50 3-d of W.C. Law) Section 302-2.1 (f) of the Workers’ Compensation Board’s Rules of Conduct for licensed representatives requires that every representative of claimants, employers and carriers: Disclosure fully to his/her client in writing on a form prescribed by the Board any adverse interest or relationship of the licensed representative or person authorized to represent the license holder with any of the parties. Adverse interests or relationship include, but are not limited to, ownership of stock or other financial interest in any party to the proceeding and representation of another party in this proceeding. Except with the consent of his/her client after the foregoing full disclosure, a representative shall not represent a client in a proceeding. If a duly designated employee of a licensed representative of self-insurers for reasons of adverse interests withdraws from representing a client, no other duly designated employee of the same licensed representative may represent that client in the same proceeding. Representation of more than one party in a proceeding is prohibited. Licensee _________________________________ Authorized Employee of Licensee (if any) _____________________ Client’s name ___________________ WCB Case No. (if any) ___________________ Representative’s Statement of Conflict of Interest ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signature of Licensee License Number _______________________ ___________________________ Date _____________ Telephone Number _______________ Client’s Statement I have read the above statement and understand same, and consent to be represented by the above licensee. Signed ___________________________ Date ________________ OC-408 (6/99) American LegalNet, Inc. www.FormsWorkflow.com