State of New York WORKERS' COMPENSATION BOARD APPLICATION FOR APPROVAL OF NON-SCHEDULE ADJUSTMENT (Please Type All Answers) We, the undersigned, jointly apply for Board approval that this claim be closed on a non-schedule adjustment ____ Section 15, Subdivision 5-b, Workers' Compensation Law ____ Section 12, Volunteer Firefighters' Benefit Law ____ Section 12, Volunteer Ambulance Workers' Benefit Law in the amount of $................................................... Claimant's Soc. Sec. No. ..................................................... W.C.B. Case No. .................................................... District Office of Hearing .......................................... Claimant Carrier Case No. ............................................................... ......................................................................................... Carrier v ......................................................................................................... s ....................................................................................................................... Employer 1. Date of accident ....................... 2. Date of application ........................ 3. Claimant's date of birth ............................... 4. Accident, Notice, Causal Relation established for: [site(s) of injury or occupational disease] ............................................... 5. Claimant is at present employed by ................................................................................................................................. Employer a. Address of employer ................................................................................................................................................. b. Weekly earnings $.................................... c. First date of such employment ........................................................... 6. List ALL sources of income and amounts, other than Workers' Compensation benefits ........................................................ ..................................................................................................................................................................................... 7. Number and birth dates of persons dependent on the claimant for support........................................................................... 8. a. Is claimant married? Yes No b. If married, is spouse employed? Yes No c. If spouse is employed, what are his/her weekly earnings? $....................... 9. Amount of monthly rent or mortgage $...................................... b. Date of classification ..................................... weekly (reduced earnings) 10. Is case closed? Yes No a. Date of closing ............................ 11. Last award was from ................................ to ................................ at $............................ 12. Total Compensation paid to date $............................. (attach Form C-8/8.6) a. Claimant's Average Weekly Wage $...................................... (as set in the Workers' Compensation case) b. If claimant was under 25 years old on the date of the accident, was wage expectancy ruled upon? 13. Therapeutic report of Dr. ............................................................................................. (attach report in ALL cases of causally related mental condition only) Yes No dated ..................................... 14. Name of claimant's Attorney or (check one) Licensed Representative .......................................................................................... 15. Fee requested $............................... (attach Form OC-400.1) b. Total prior fees $......................... Yes No c. Are any fees unpaid? Yes No 16. Is claimant receiving medical treatment? (for causally related disability) Give date of last compensable treatment................................. (See Note 1(b) on reverse) Yes No If No, are medical bills being controverted for 17. Have all medical bills for past treatment been paid? reasons which require resolution by a Workers' Compensation Law Judge? Yes No 18. Are there any issues pending before the Workers' Compensation Law Judge on: a. 15(8)? b. 25-a? Yes No Yes No No c. Overpayment? Yes No Yes No d. Apportionment? Yes e. Are there any other unresolved issues? If yes, list unresolved issues ........................................................................ Yes No 19. Is a related action pending against a third party or a question of deficiency compensation not yet resolved? 20. If there are outstanding issues, can they be resolved by stipulation? resolved by stipulation(s) Yes No If yes, list those issues that can be Yes No 21. Is there currently a child support lien on Workers' Compensation benefits ordered by the Family Court? If yes, has the Support Collection Unit of your County been notified of this settlement? Yes No (Attach written agreement from the Support Collection Unit of your County to the terms of this proposed settlement.) Yes No If No, will he or she be present at the non22. Does the claimant currently reside in New York State? Yes No If No, interrogatories must be submitted with this form together with an schedule adjustment hearing? UP-TO-DATE MEDICAL REPORT. (See Note 1(c) on reverse.) 23. Is an interpreter needed for the lump sum hearing? Yes No If yes, indicate language required: ............................. C-22 (1-11) (Over) American LegalNet, Inc. www.FormsWorkFlow.com 24. Give complete details of the claimant's plan for use of the proceeds of the adjustment, if and when approved by the Board. (Use additional sheets, if necessary, and attach to this form.) ....................................................................... ............................................................................................................................................................................. ............................................................................................................................................................................. 25. Does the claimant fully understand that if the adjustment is approved, his/her case is closed and cannot, under the Workers' Compensation Law, be reopened unless the Board shall find that the claimant's disability related to his/her Workers' Compensation case has changed for the worse in condition or in the degree of disability not found in the medical