STATEMENT OF REGISTRATION Section 13-n, WCL IME Entity Pursuant to Section 13-n and 12 NYCRR 300.2 of the Workers' Compensation Law, any entity which derives income from independent medical examinations performed in accordance with Sections 13-a(4), 13-k(3), 13-l(3) or 13-m(4), of the WCL or review or records, whether by employing or contracting with independent examiners to conduct such independent medical examinations or review of records or by acting as a referral service or otherwise facilitating such examinations, shall register with the Chair by filing a statement of registration containing such information prescribed by the Chair in regulation. Instructions: Complete all items below and on reverse, attach additional sheet if necessary. Please print or type. Illegible forms will be returned. A registration fee of $250 payable to the Chair, Workers' Compensation Board, must accompany each submission. Send completed statements to: Workers' Compensation Board, Medical Director's Office, 100 Broadway - Menands, Albany, NY 12231. You must resubmit this registration every three years together with the registration fee. In the event that your company has a change of name, officers, owners or partners, or a change of any address or business location, you must notify the Board within 30 days. For updates to registration or electronic transmission please e-mail: IMEEntityRegistration@wcb.ny.gov. 1. Entity Name(s) as registered with Department of State (attach copies of the organizational documents for the entity, such as articles of incorporation or articles of organization): WORKERS' COMPENSATION BOARD STATE OF NEW YORK Federal Tax ID No(s).: 2. Name(s) under which entity conducts business: 3. Name, title and phone number of contact person for the entity: 4. Address(es) of entity's administrative offices: 5. Name, title, address and telephone number of each of the entity organization's officers, owners and partners: 6. Have any of the officers, owners or partners been convicted of any criminal offense? If Yes, please explain: Yes No 7. Describe the services provided by the entity and its employees or independent contractors, including a description of the relationship between the entity and its owners, officers or partners and its employees or independent contractors: IME-7 (7-14) CONTINUED ON REVERSE American LegalNet, Inc. www.FormsWorkFlow.com 8. Describe the relationship between the IME entity and its owners, officers and partners and the independent medical examiners it employs or with whom it contracts to conduct independent medical examinations or review of records: 9. List the names and addresses of all organizations that are affiliated with, share common ownership with, own or are owned by the IME entity, including but not limited to other IME entities required to register with the New York State Workers' Compensation 10. Is the entity owned by, or does it share common ownership with, or is it affiliated with an insurance carrier or third-party Yes No administrator? If Yes, please provide explanation of relationship and legal name of affiliated entities: 11. Does the entity subcontract or contract with an organization that is not a registered IME entity to perform any ancillary services Yes No related to independent medical examinations or review of records? If yes, attach a separate statement identifying each such organization and affirming that such ancillary services performed by a subcontractor do not require registration as an IME entity as they are not functions central to the examination or review of records such as identifying and retaining the services of an examiner, scheduling of the examination, mailing of the report of independent medical examination or review of records and any related notices or Board forms, and negotiation of payment for the examination or review of records. STATE OF NEW YORK County of } AFFIRMATION ss.: , being duly sworn, depose(s) and say(s) that (s)he is the of the entity named in the foregoing statement of registration; that (s)he has read the same and know(s) the contents thereof; and that the same is true to his/her own knowledge. Deponent further says that the is a (name of entity) (type of business, e.g., corporation, partnership, PLLC) entity and deponent is an officer thereof, to-wit its (deponent's title). Deponent further says that the entity registering with the Chair, Workers' Compensation Board, is organized under the laws of New York State in a business form that is recognized by the laws of New York State or in the state in which it is incorporated, is duly registered with the Department of State, and is in full compliance with the laws of the State of New York, its state of incorporation if outside of New York, and the United States, including but not limited to any laws or regulations under the Public Health Law, the Education Law and the Workers' Compensation Law governing the practice of medicine, podiatry, chiropractic and psychology, treatment of injured or ill workers, solicitation and fee-splitting, and any laws or regulations under the jurisdiction of the state Department of Insurance, the federal Health Care Financing Administration, the State Department of Taxation and Finance or the federal Internal Revenue Service. Deponent will supply any material changes to this information to the Board within thirty days of such change. Deponent shall reregister with and submit the registration fee to the Board every three years. Sworn to before me, this day of 20 Notary Public IME-7 REVERSE (7-14) American LegalNet, Inc. www.FormsWorkFlow.com