TO CHAIR State of New York WORKERS' COMPENSATION BOARD NOTICE OF RETAINER AND APPEARANCE ON BEHALF OF EMPLOYERvs.Please take notice that the employer named above hereby appears in the above matter, and that the undersigned attorney has been retained to represent said employer in regards to the above matter. All notices, decisions and other documents in the above case are to be sent to the undersigned attorney at the address indicated below. Please take notice that I have retained the above named attorney to represent and appear by and on behalf of the employer in all proceedings in regards to the above matter.* In a No-Insurance Case the "Alleged Employer."OC-406 (1-18) This form is for use by employers and their attorneys ONLY. An attorney retained by an employer's insurance carrier is not permitted to use this form. Both the attorney and the employer must sign this form.An R Number is required for eCase [electronic case folder] access. Information about eCase and obtaining an R Number is available at the Workers' Compensation Board's website, www.wcb.ny.gov, under the heading Representatives. Claimant * EmployerSpecific information is required to identify the case(s) you have been retained for in reference to the claimant and employer named. Please provide this information and circle: Case Number (includes WCB, DB, DC, and PFL), Date of Accident, Paid Family Leave ("PFL"), Start Date or PFL Discrimination Complaint Date, to indicate the type of information you have provided. Use one line per case. Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date Date: Printed Name of Attorney: Office Address: Signature of Attorney Office Telephone Number: Attorney's Board-assigned ID Number, if any: Date: Signature of Person Authorized to Sign on Behalf of Employer Title of Person Authorized to Sign on Behalf of Employer Printed Name of Person Authorized to Sign of Behalf of Employer American LegalNet, Inc. www.FormsWorkFlow.com