STATE OF NEW YORK WORKERS' COMPENSATION BOARD DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 100 Broadway Menands ALBANY 12241 State Office Building 44 Hawley Street BINGHAMTON 13901  0DLQ 6WUHHW 6XLWH  BUFFALO 1420 130 Main Street W. ROCHESTER 14614 935 James Street SYRACUSE 13203 COVER SHEET - APPLICATION FOR RECONSIDERATION / FULL BOARD REVIEW WCB Case Number(s) Carrier Case Number(s) Carrier Code Date of Injury Carrier's Name Claimant's Name Address TO THE APPLICANT: This Application for Reconsideration / Full Board Review may be filed with the Board by fax (1-877-533-0337; see Subject No. 046-144), e-mail (wcbclaimsfiling@wcb.state.ny.us; see Subject Nos. 046-144 and 046-375), personal delivery to a Board District Office, or by mailing to one of the Board addresses listed at the top of this page. A copy of this Application must be served on all parties in interest. Sections 1 and 2 on the reverse side of this form must be completed. The failure to supply all information requested by this form may result in dismissal of the Application. If an additional attorney fee is being requested, Form OC-400.1 must be attached and served on all parties. For Applications filed by a carrier, TPA or self-insured employer, an up-to-date Form C-8/8.6 must be attached and served on all parties. TO ALL OTHER PARTIES: Any Rebuttal to this Application must be served on the Board within 30 days following the date on which the Application was served on the parties, as specified in Section 2 on the reverse side of this form. 1. This application is made on behalf of: Claimant Employer/Carrier Special Funds Uninsured Employers' Fund (name) Attorney/Licensed Representative 2. The filing date of the Memorandum of Decision by the Board Panel is 3. This application for Reconsideration / Full Board Review under WCL § § 23 and 142[2] is: Mandatory (there was a dissent other than the sole basis of which is referral to an impartial specialist) Discretionary 4. The remedy sought is: Administrative Correction of the Memordandum of Decision Modification of the Memorandum of Decision Reversal of the Memorandum of Decision Rescission of the Memorandum of Decision 5. This case is presently (check one): Disallowed Established 6. Specify the issue(s) for review: Employer/employee relationship Average Weekly Wage Special Funds Liability Accident Authorization of Treatment Attorney/Licensed Representative Fee Occupational Disease Period of Disability Facial Award Notice Degree of Disability Section 32 Denial Causal Relationship Reimbursement Disability Benefits Death Benefits Penalty Discrimination Timely Claim Filing WCL § 114-a Disqualification Policy Coverage Jurisdiction Apportionment ATF Deposit 7. Specify the grounds for review (foundation, basis, or points) relied upon in raising the issues identified above. 8. Make reference to the record below, or such part thereof, as is relevant to the issue(s) and ground(s) raised in this application. Also, indicate when and where such issue(s) and ground(s) were raised before the Workers' Compensation Law Judge. Hearings (if minutes are not transcribed, so indicate): Documents: provide name and document ID number: RB-89.2 () THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com Transcripts: provide date and document ID number: Non-Scanable Evidence or Videotape (WMV or AVI format only): provide description: 9. Has or will an appeal to the Memorandum of Decision be taken to the Appellate Division of the Supreme Court, Third Department? Yes No Certification: By signing this document in the space provided below, I certify that this application has a good faith basis in law and fact, has been instituted with reasonable grounds, and has been served upon all parties at the addresses listed in the affirmation or affidavit of service below. I understand that the Workers' Compensation Law provides for substantial penalties for instituting or continuing proceedings without reasonable grounds and/or for the purpose of delay. I understand that if this application is withdrawn for any reason or if any of the issues raised are resolved by the parties, I must immediately notify the Board and the parties served in writing. Signature of Person Preparing Form Date ______/______/______ Print Name Title Phone Number (______)______________ Address SECTION 1 AFFIRMATION STATE OF NEW YORK, COUNTY OF ________________ ss: I, the undersigned, am an attorney duly admitted to the practice of law in the courts of the state of New York. I hereby certify that I have complied with the filing and service requirements for this Application for Full Board Review in the manner described in Section 2 below. I affirm that the foregoing statements are true under penalties of perjury. Dated ______________________ Signature _______________________________________________________ Signer's Name (Print) ______________________________________________ __________________________________________________________________________________ AFFIDAVIT STATE OF NEW YORK, COUNTY OF ________________ ss: I, _______________________________________________________, being duly sworn, say: I am over 18 years of age. I hereby certify that I have complied with the filing and service requirements for this Application for Full Board Review in the manner described in Section 2 below. Sworn to before me on _________________ Signature ___________________________________________________________ ____________________________________ Notary Public Signer's Name (Print) _________________________________________________ SECTION 2 A. Method by which Application was Filed with the Board (Check One): Fax (1-877-533-0337) E-Mail (wcbclaimsfiling@wcb.state.ny.us) Date of Mailing: __________________________ B. Method of Service on the Parties (Check One): Mail (specify date below) Personal Delivery (specify date below) Date of Personal Delivery:____________________________ Mail Personal Delivery Specify Date of Mailing or Personal Delivery ____________________________ C. Names and addresses of all Parties Served: (Attach additional sheets if necessary.) RB-89.2 () American LegalNet, Inc. www.FormsWorkFlow.com