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Licensed Representatives Disclosure Of Conflict Of Interest To Client Form. This is a New York form and can be use in Workers Compensation.
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Tags: Licensed Representatives Disclosure Of Conflict Of Interest To Client, OC-408, New York Workers Compensation,
State of New York
WORKERS' COMPENSATION BOARD
LICENSED REPRESENTATIVE’S DISCLOSURE OF CONFLICT OF INTEREST TO CLIENT
(Section 24a, 50 3-b and 50 3-d of W.C. Law)
Section 302-2.1 (f) of the Workers’ Compensation Board’s Rules of Conduct for licensed
representatives requires that every representative of claimants, employers and carriers:
Disclosure fully to his/her client in writing on a form prescribed by the Board any
adverse interest or relationship of the licensed representative or person authorized to
represent the license holder with any of the parties. Adverse interests or relationship
include, but are not limited to, ownership of stock or other financial interest in any party
to the proceeding and representation of another party in this proceeding. Except with the
consent of his/her client after the foregoing full disclosure, a representative shall not
represent a client in a proceeding. If a duly designated employee of a licensed
representative of self-insurers for reasons of adverse interests withdraws from
representing a client, no other duly designated employee of the same licensed
representative may represent that client in the same proceeding. Representation of more
than one party in a proceeding is prohibited.
Licensee
_________________________________
Authorized Employee of
Licensee (if any)
_____________________
Client’s name
___________________
WCB Case
No. (if any)
___________________
Representative’s Statement of Conflict of Interest
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature of Licensee
License Number
_______________________
___________________________
Date
_____________
Telephone Number
_______________
Client’s Statement
I have read the above statement and understand same, and consent to be represented by the above
licensee.
Signed ___________________________
Date ________________
OC-408 (6/99)
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