Intial Designation of Authorized Representatiives Designation of Additional Authorized Representatiives Supersedes DB-840 Dated__________________ WORKERS' COMPENSATION BOARD DISABILITY BENEFITS BUREAU 328 STATE STREET SCHENECTADY, NY 12305 STATE OF NEW YORK THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. CARRIER'S DESIGNATION OF AUTHORIZED REPRESENTATIVES TO: Chair, Workers' Compensation Board The following are hereby designated as the authorized representatives of the undersigned insurance carrier in matters relating to Disability Benefits, as follows: (A) 1. Acceptance of Insurance Contracts 2. Address Tel. No. 1. Address Tel. No. 2. Address Tel. No. 1. Address Tel. No. 2. Address Tel. No. NAME AND SIGNATURE Address Tel. No. DISTRICT OR REGIONAL OFFICE ADDRESS ( Zip Code,Telephone Number and Area Code) (B) Acceptance of Plans (C) Claims The undersigned agrees to notify the Chair promptly if and when any subsititutions are made or additional representatives are authorized. ______________________________________________ (Name of Insurance Carrier) ______________________________________________ (Home Office Address) Date________________________ Tel. No.______________________ By___________________________________________ Title__________________________________________ If District or Regional Claims offices are maintained, attach a list giving the name, signature, address and telephone number of EACH AUTHORIZED CLAIMS REPRESENTATIVE and indicating the counties of New York State included in the District or Region under the supervision of each such office. TO BE FILED IN TRIPLICATE Page______of______ DB-840 (2-00) American LegalNet, Inc. www.FormsWorkFlow.com