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  0DLQ 6WUHHW 6XLWH  BUFFALO 1420 State Office Building 44 Hawley Street BINGHAMTON 13901 130 Main Street W. ROCHESTER 14614 935 James Street SYRACUSE 13203 COVER SHEET - REBUTTAL OF 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 SENDER: This Rebuttal of an 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 Rebuttal 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 Rebuttal. 1. This rebuttal is made on behalf of: Claimant Employer/Carrier Special Funds Uninsured Employers' Fund (name) 2. This rebuttal is in response to an application for: Mandatory Full Board Review (choose only one) Discretionary Full Board Review 3. The application was served upon the above cited party on: 4. The filing date of the Memorandum of Decision which is the subject of the application for Reconsideration / Full Board Review is: 5. This rebuttal contends that the: Application for Reconsideration / Full Board Review should be denied. Memorandum of Decision should be administratively corrected to read: Memorandum of Decision should be affirmed in its entirety Memorandum of Decision should be modified as to: 6. As to the finding(s) of fact and/or conclusion(s) of law made in the decision, this rebuttal contends: 7. Does the record cited in the application constitute the full record for review?: If Yes, do you rest on that record?: Yes Yes No No If No, and you contend that the record cited in the application does not constitute the full record for review, provide below the additional hearings, documents, and transcripts in the WCB's electronic file that are relevant to the issue(s) and ground(s) raised in the application, were not cited on the application, and complete the record for review: Hearings: provide date(s) where issue(s) was raised before the Workers' Compensation Law Judge and evidence presented pertaining to the issue(s) and ground(s) raised and document ID number if applicable. If hearing minutes have not been transcribed, so indicate: Documents: provide name and document ID number: RB-89.3 () 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: Certification: By signing this document in the space provided below, I certify that this rebuttal 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 the application for Board review is withdrawn for any reason or if any of the issues raised are resolved by the parties, the Board and the parties served must be notified immediately in writing. Signature of Person Preparing Form Date ______/______/______ Title Print Name Phone Number (______)______________ 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 Rebuttal of an 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 Rebuttal of an Application for 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 Rebuttal was Filed with the Board (Check One): Fax (1-877-533-0337) E-Mail (wcbclaimsfiling@wcb.state.ny.us) Mail (specify date below) Personal Delivery (specify date below) Date of Mailing: _____________________________ Date of Personal Delivery:_______________________________ B. Method of Service on the Parties (Check One): Mail Personal Delivery Specify Date of Mailing or Personal Delivery ____________________________ C. Names and addresses of all Parties Served: (Attach additional sheets if necessary.) RB-89.3 () Reverse American LegalNet, Inc. www.FormsWorkFlow.com