State of New York WORKERS' COMPENSATION BOARD CARRIER'S/EMPLOYER'S REQUEST FOR FURTHER ACTION INSTRUCTIONS: To request Board action on a case, submit this form to the local WCB district office. See mailing addresses on the reverse side. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. A copy of this form must also be sent to the claimant, and his/her representative, if any. If item 11a is checked, a copy must also be filed with claimant's attending health care provider. This form is NOT to be used to APPEAL a decision. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. WCB CASE NO. 2. 3. CARRIER CODE CARRIER CASE NO. 4. mm 5. DATE OF INJURY dd y SOCIAL SECURITY NO. 6. DISTRICT OFFICE y W NAME ADDRESS TO WHICH NOTICES SHOULD BE SENT APT. NO. 7. CLAIMANT 8. EMPLOYER 9. CARRIER ATTY/REP I.D. NO. 10. ATTORNEY OR LICENSED REP. CHECK HERE R IF CLAIMANT'S ADDRESS SHOWN ABOVE IS NEW REASON FOR THIS REQUEST (Check all that apply - use item l. for explanation or additional information) 11. CARRIER/EMPLOYER c. has evidence of voluntary removal from the labor market. a. contends that continuing payments should be: Suspended Reduced to $__________ per week based on: evidence of change in medical condition pursuant to Rule 300.23. payroll evidence warranting a rate modification under Rule 300.23. d. requests referral to conciliation (WCL 25(2-b) and Rule 312) on the issue of_____________________________________ _________________________________________________ e. requests resolution by administrative determination (Rule 313) ATTACH MEDICAL OR PAYROLL EVIDENCE SUPPORTING YOUR POSITION. IF MEDICAL EVIDENCE WAS PREVIOUSLY SUBMITTED, IDENTIFY IT IN ITEM l BELOW BY DATE, DOCTOR'S NAME AND FORM ID, IF ANY. f. has evidence relating to disqualification under WCL 114-a. b. in response to a request to reopen, contends under Rule 300.22(e) that: payments have resumed from ________________ to _____________ at a weekly rate of $____________. payments have resumed as indicated above without prejudice and without admitting liability (WCL 21-a). g. requests relief under WCL 15(8), 25-a or 14(6). h. has new or requested evidence. i. has payroll evidence relating to reduced earnings. j. has evidence of the settlement of a third party action. the right to compensation is not disputed, but: no payments are due. Necessary medical treatment is authorized. k. requests a resolution regarding schedule loss of use or facial disfigurement. payments have not begun (explain below). the right to compensation is disputed (explain below). l. other (please specify in the space provided below.) ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. IF MEDICAL EVIDENCE WAS PREVIOUSLY SUBMITTED, IDENTIFY IT BY DATE, DOCTOR'S NAME AND FORM ID, IF ANY, IN THE SPACE PROVIDED ABOVE. 12. Have the above issues been resolved by agreement? If Yes, please attach documentation. Yes No If No, have you attempted to resolve the issue(s) checked above with the other parties? Yes No I hereby certify that a copy of this form with attachment(s) was submitted to the other party(ies) in this case in accordance with the instructions above. DATE PREPARED PREPARED BY (Please Print Name) mm This form is submitted by RFA-2 (8-09) carrier dd y y AREA CODE TELEPHONE NUMBER self-insurer SEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO American LegalNet, Inc. www.FormsWorkFlow.com TO THE CARRIER/EMPLOYER This form may be filed by the insurance carrier or employer in a workers' compensation case when it wants the Workers' Compensation Board to take action in the case. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. A copy of this form must also be sent to the claimant, and his/her representative, if any. ITEM 11a replaces Form C-22b. If item 11a is checked, a copy must be filed with claimant's attending doctor. (See additional information below regarding item 11a). ITEM 11b replaces Form RB-679. If item 11b is checked, this form must be filed within 25 days after receiving an application to reopen a case previously established and designated closed or no further action by the Board. If the employer becomes aware that a claimant whose case has been designated closed or no further action by the Board has begun to lose additional time, the employer or carrier may begin temporary payments of compensation immediately. ITEM 11d replaces Form CB-8. All uncontested claims where the expected duration of benefits is 52 weeks or less should be resolved in conciliation [Rule 312.2]. ITEM 11e - All uncontested claims involving only temporary minor injuries should be resolved through administrative determination [Rule 312.2[a]]. TO THE CLAIMANT If you have any questions regarding the action being requested by the carrier/employer, please contact the nearest office of the Board. If you have retained legal counsel to represent you, you may contact him/her for assistance. Please remember to always use the WCB Case Number shown on the other side of this form when corresponding with the Board. AL RECLAMANTE Si tiene alguna pregunta en relación a la acción solicitada por el patrono ó el seguro favor de comunicarse con la oficina más cercana de la Junta. Si está representado legalmente, debe comunicarse con sú representante para asesoramiento. Cuando se comunique con la Junta, siempre use el número de caso WCB que aparece en el otro lado de esta notificación. Regarding Item 11a. - Board Rule 12 NYCRR 300.23 This notice (item 11a) replaces Form C-22b for the purpose of notifying the Board of the carrier/employer's intention to reduce or suspend the claimant's payments in accordance with Board Rule 12 NYCRR 300.23. This notice may be filed in any case where there has been an award and a direction for continuation of payments and evidence is presented to support the suspension of payments or reduction in rate. The Board, upon receipt of this notice and attachments, may either schedule a WC LAW JUDGE HEARING on this issue within 20 days during any period in which regular hearings are scheduled, or refer the matter to the Administrative Review Division for a determination of whether a reopening is warranted. In the event that the Administrative Review Division directs that the case be reopened, a WC Law Judge Hearing will be scheduled in an expeditious manner. IF THE REQUIRED DOCUMENTATION IS NOT ATTACHED, THE CASE WILL NOT BE SCHEDULED FOR A HEARING. Cases at hearing points which do not have regularly scheduled hearings within 20 days may be scheduled at another hearing point. At the time a WC Law Judge hearing is held, either immediately after the Board's receipt of this notice and attachments or at the direction of the Administrative Review Division, the WC Law Judge will consider all available evidence and decide whether or not payments may be suspended or reduced. PAYMENTS SHALL CONTINUE, AS DIRECTED, until there is a determination by the WC Law Judge that such payments may be suspended or reduced. TO THE CLAIMANT - Regarding Item 11a Please read this notice and attachments carefully. If item 11a is checked, this notice means that your employer (if self-insured) or its insurance company wants to suspend or reduce your compensation payments, for the reason indicated. As explained above, your case may be scheduled for a hearing on this issue. Be sure to BE PRESENT, if you disagree with your employer or his/her insurance company. If you are NOT PRESENT, the W.C. Law Judge will make a decision based on available evidence. If your employer or his/her insurance company contends that your compensation payments should be suspended or reduced because your medical condition has improved (not because your earnings have increased), BRING TO YOUR HEARING THE MOST RECENT MEDICAL REPORT FROM YOUR DOCTOR THAT DESCRIBES YOUR CURRENT MEDICAL CONDITION. Section 114 of the Workers' Compensation Law provides, in part, that any employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who knowingly makes a false statement or representation as to a material fact for the purpose of avoiding provision of any payment or benefit under this chapter shall be guilty of a felony. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 100 Broadway State Office Building Menands 935 James St. 44 Hawley Street 369 Franklin Street 130 Main Street W. ALBANY 12241 BINGHAMTON 13901 BUFFALO 14202 ROCHESTER 14614 SYRACUSE 13203 NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 (866) 750-5157 (866) 211-0645 (866) 211-0644 (866) 802-3730 (866) 802-3604 RFA-2 (8-09) Reverse Statewide Fax Line: 877-533-0337 www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com