*If claim is made under the Volunteer Firefighters' Benefit Law or the Volunteer Ambulance Workers' Benefit Law, show as EMPLOYER the liable political subdivision and enter "X" in the appropriate boxC.FOR SUBSTITUTION ONLY - ATTORNEY/REPRESENTATIVE COMPLETE THIS SECTIONOC-400 (1-18)SEE IMPORTANT INFORMATION ON REVERSESTATE OF NEW YORK - WORKERS' COMPENSATION BOARDCHECK ONE NOTICE TO ATTORNEY OR REPRESENTATIVE:original,substitutedoradditionalallmustA.CLAIMANT COMPLETE THIS SECTION CHECK ONE:(CHECK ONE): I am (CHECK ONE):ATTORNEY OR REPRESENTATIVE WHO IS TO APPEAR, IF OTHER THAN YOURSELFD.REQUEST AND NOTICE TO HEALTH PROVIDER Please Note: A photocopy of this notice shall be deemed as effective as an original.B.ATTORNEY/REPRESENTATIVE COMPLETE THIS SECTIONE.CERTIFICATION OF TRANSMITTAL OF THIS NOTICE TO INSURANCE CARRIER/SELF-INSURED EMPLOYER/EMPLOYER NOTICE OF RETAINER AND APPEARANCE NOTICE OF SUBSTITUTION AND APPEARANCE (For substitutions, item C MUST also be completed.) NOTICE OF RETAINER AND APPEARANCE - ADDITIONAL ATTORNEY American LegalNet, Inc. www.FormsWorkFlow.com RULES AND PROCEDURE OF THE WORKERS' COMPENSATION BOARD12NYCRR 300.17 Notices of Retainer, Appearance and Substitution, and Fees of Claimant's Attorney or Licensed RepresentativeOC-400 Reverse (1-18)www.wcb.ny.gov NYS Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205 Customer Service: (877) 632-4996 Statewide Fax: (877) 533-0337 American LegalNet, Inc. www.FormsWorkFlow.com