RB-89 (11-18) Instructions1.WCB Case Number(s). Enter the WCB Case Number(s) of the claim(s) being appealed. WCB Case Number(s) includes thecase number for workers' compensation, discrimination, disability benefits, paid family leave discrimination, volunteer firefighter and volunteer ambulance worker benefits. 2.Carrier Case Number(s). Enter the Carrier Case Number(s) of the claim(s) being appealed. This section/item does not applyto claims for discrimination. 3.Carrier Code. Enter the Carrier Code of the insurer for the claim being appealed. This section/item does not apply to claimsfor discrimination. 4.Carrier's Name. Enter the name of the Carrier for the claim being appealed. This section/item does not apply to claims fordiscrimination. 5.Date of Injury/Leave. Enter the original date that the injury occurred or the date paid family leave began (if paid family leavewas not taken, enter the Discrimination Complaint Date). 6.Claimant's Name. Enter the complete name of the employee.7.Claimant's Address. Enter the street address, city, state and ZIP code of the employee, and mailing address if different.8.Party Requesting the Appeal. Indicate which party is filing this Application for Board Review.9.Type of Application. Indicate whether the Application is requesting either 1) review of a WCLJ Decision, or 2) rehearing orreopening. 10.Date of Decision. Enter the date of the decision that is being appealed.11.Specify the Issue(s) for Review. State the specific issue(s) for review.12.Basis of Appeal. Provide a brief statement of the particular grounds upon which the appeal is based, including the specificfindings of fact which are challenged and/or the errors of law which are alleged. General allegations which do not specifically bring to the attention of the Board the issues to be decided are insufficient. As prescribed by 12 NYCRR 300.13(b)(1)(i), an appellant may attach a legal brief of up to eight (8) pages in length, using 12-point font, with one inch margins, on 8.5-inch by 11-inch paper. A brief longer than eight (8) pages will not be considered, unless the appellant specifies in writing, why the basis of the appeal could not have been made within eight (8) pages. A brief longer than fifteen (15) pages will not be considered under any circumstances. INSTRUCTIONS FOR COMPLETING RB-89 TO THE APPLICANT: An Application for Board Review must be filed within 30 calendar days after the filing date of the WCLJ's decision. An Application is deemed filed with the Board on the date of actual receipt of such Application by the Board. In accordance with 12 NYCRR 300.13(b)(3) and the Chair's designation, an Application may only be filed with the Board at the Board's centralized mailing address (P.O. Box 5205, Binghamton, NY 13902-5205), centralized fax number for claims (1-877-533-0337), centralized Email address for claims (wcbclaimsfiling@wcb.ny.gov), or via the WCB Web Upload link (https://wcbdoc.services.conduent.com/ ). Applications in workers' compensation discrimination claims must be filed with the Board by mailing the Application to the Board's Discrimination Unit, Riverview Center - 150 Broadway, Menands, NY 12204. Applications in claims filed for disability benefits (claims for lost wages due to injuries or illnesses that are not work-related) must be filed with the Board by mailing the Application to the Disability Benefits Bureau, PO Box 9029, Endicott, NY 13761-9029. A copy of this Application must be served upon all necessary parties of interest in accordance with 12 NYCRR 300.13(b)(2)(iv). Applications, unless submitted by an unrepresented claimant, must be in the format prescribed by the Chair, all sections of the Application must be completed, and any legal brief attached must comply with 12 NYCRR 300.13(b)(1)(i). Failure to supply all information required by 12 NYCRR 300.13 and these instructions may result in the Application being denied. If requesting or participating in voluntary binding review, this form must be filed within 30 calendar days after the filing date of the WCLJ's decision by mailing, faxing, emailing, or web upload as stated above. NOTE: Applications for Board Review will not be accepted if hand delivered to a Board office. Applications mailed or submitted directly to the Administrative Review Division will be deemed to have not been filed with the Board and will not be considered. TO ALL OTHER PARTIES: Any Rebuttal to this Application must be served on the Board within 30 calendar days following the date on which the Application was served on the parties, as specified in the Proof of Service section of the RB-89 form in accordance with 12 NYCRR 300.13(c). American LegalNet, Inc. www.FormsWorkFlow.com 13.Hearing Dates, Transcripts, Documents, Exhibits, and Other Evidence. Indicate the hearing date(s) on which theissue(s) was raised before the WCLJ, as well as any other relevant hearing dates. Identify by date and/or documents ID number(s) the transcripts, documents, reports, exhibits, and other evidence in the Board's file that are relevant to the issues and grounds being raised for review. If minutes are not transcribed, so indicate. Do not include with or attach to an Application for Board Review any documents that are present in the Board's file at the time the Application is filed. The Board may reject an Application for Board Review by an appellant or an appellant's legal representative who attaches documents already in the Board's file at the time of the Application, in accordance with 12 NYCRR 300.13(b)(1)(ii). Do not attach or submit transcripts of audio recorded hearings, as the Board will not consider them. 14.New and Additional Evidence. If an appellant seeks to introduce new or additional evidence with the Application for BoardReview that was not presented before the WCLJ, the appellant must, 1) state on the Application whether such evidence is attached to the Application, or is in the Board's file, specifying the applicable document ID number, and 2) submit a sworn affidavit or affirmation setting forth the evidence, and explaining why such evidence could not have been presented before the WCLJ. The Board may or may not exercise its discretion to accept such evidence. If the sworn affidavit or affirmation is not submitted with the Application, such new or additional evidence will not be considered by the Board Panel [see 12 NYCRR 300.13(b)(1)(iii)]. 15.Objection or Exception. Specify the objection or exception that was interposed to the ruling, and the date when theobjection or exception was interposed as required by 12 NYCRR 300.13(b)(2)(ii). If the objection or exception was interposed at a hearing, the date of the hearing at which the objection or exception was interposed must be stated. If the objection or exception was interposed at a proceeding occurring off-calendar, the date of the off-calendar proceeding must be stated [12 NYCRR 300.13(b)(4)(v)(a), (b), and (c)]. 16.Indemnity Payments. When the Application is filed by the carrier or self-insured employer, indicate whether indemnitybenefits are being paid while the application is pending. If no, indicate the date on which payments were suspended pursuant to WCL 247 23. If yes, indicate the rate at which continuing indemnity benefits are being paid. If continuing indemnity benefits are being paid at a rate that is less than the awarded rate, specify the date on which payments were reduced. If payments are stayed, state the issue on appeal that forms the legal basis for staying payments. This item/section does not apply to claims for discrimination. 17.Attorney's fees. When the Application is filed by the claimant's legal representative, indicate whether an increase inattorney's fees is being requested. If yes, Form OC-400.1, Application for a Fee by Claimant's Attorney or Representative, must be attached and served on the parties [see12 NYCRR 300.13(b)(2)(v) and 300.17)]. Failure to request an additional fee in the Application for Board Review, and by filing a Form OC-400.1 with the Application, shall result in the waiver of any additional fee. 18.Certification. The preparer must sign and date the form (also providing their name, title, tel