RB-89.1 (11-18) Instructions1. WCB Case Number(s). Enter the WCB Case Number(s) of the claim(s) being appealed. WCB Case Number(s) includes the case number for workers' compensation, discrimination, disability benefits, paid family leave discrimination, volunteer firefighter and volunteer ambulance worker benefits. 2. Carrier Case Number(s). Enter the Carrier Case Number(s) of the claim(s) being appealed. This section/item does not apply to claims for discrimination. 3. Carrier Code. Enter the Carrier Code of the insurer for the claim being appealed. This section/item does not apply to claims for discrimination. 4. Carrier's Name. Enter the name of the Carrier for the claim being appealed. This section/item does not apply to claims for discrimination. 5. Date of Injury/Leave. Enter the original date that injury occurred or the date paid family leave began (if paid family leave was not taken, enter the Discrimination Complaint Date). 6. Claimant's Name. Enter the complete name of the employee. 7. Claimant's Address. Enter the street address, city, state and ZIP code of the employee. 8. Party Filing this Rebuttal. Indicate which party is filing this Rebuttal. 9. Type of Application to which the Rebuttal Responds. Indicate whether the Rebuttal is in response to either a request for 1) review of a WCLJ Decision, or 2) rehearing or reopening. 10. Date of Decision. Enter the date of the decision that is being appealed. 11. Date of Service. Enter the date the Application was served upon the Respondent. 12. Requested Outcome. Indicate whether the rebuttal contends that the 1) Application should be denied under 12 NYCRR 300.13(b)(4), 2) WCLJ Decision should be administratively corrected and how it should be corrected, 3) WCLJ Decision should be affirmed in its entirety, or 4) WCLJ Decision should be modified and how it should be modified. 13. Response to Issues and Grounds. Provide a brief statement in response to the issues and grounds raised in the Application, identifying any alleged misstatements of fact or law. As prescribed by 12 NYCRR 300.13(b)(1)(i) and (c), a respondent may attach a legal brief of up to eight (8) pages in length, using 12-point font, with one inch margins, on 8.5-inch by 11-inch paper. A brief longer than eight (8) pages will not be considered, unless the respondent specifies in writing, why the basis of the appeal could not have been made within eight (8) pages. A brief longer than fifteen (15) pages will not be considered under any circumstances. INSTRUCTIONS FOR COMPLETING RB-89.1 TO THE RESPONDENT: A Rebuttal of Application for Board Review must be filed within 30 calendar days after service of the Application for Board Review upon the Respondent. A Rebuttal is deemed filed with the Board on the date of actual receipt of such Rebuttal by the Board. In accordance with 12 NYCRR 300.13(c), which requires all rebuttals to conform to the requirements in 12 NYCRR 300.13(b), a Rebuttal may only be filed at the Board's centralized mailing address (P.O. Box 5205, Binghamton, NY 13902-5205), centralized fax number for claims (1-877-533-0337), centralized email address for claims (wcbclaimsfiling@wcb.ny.gov), or via the WCB Web Upload link (https://wcbdoc.services.conduent.com/ ). Rebuttals in workers' compensation discrimination claims must be filed with the Board by mailing the Rebuttal to the Board's Discrimination Unit, Riverview Center - 150 Broadway, Menands, NY 12204. Rebuttals in claims filed for disability benefits (claims for lost wages due to injuries or illnesses that are not work-related) must be filed with the Board by mailing the Rebuttal to the Disability Benefits Bureau, PO Box 9029, Endicott, NY 13761-9029. A copy of this Rebuttal must be served upon all necessary parties of interest in accordance with 12 NYCRR 300.13(b)(1)(iv). Rebuttals, unless submitted by an unrepresented claimant, must be in the format prescribed by the Chair, all sections of the Rebuttal must be completed, and any legal brief attached must comply with 12 NYCRR 300.13(b)(1)(i). Failure to supply all information required by 12 NYCRR 300.13 and these instructions, may result in the Rebuttal not being considered. If requesting or participating in voluntary binding review, this form must be filed within 30 calendar days after service of the Application by mailing, faxing, emailing, or web upload as stated above. NOTE: Rebuttals of Application for Board Review will not be accepted if hand delivered to a Board office. Rebuttals mailed or submitted directly to the Administrative Review Division will be deemed to have not been filed with the Board and will not be considered. American LegalNet, Inc. www.FormsWorkFlow.com 14. Record. If the record cited in the application constitutes the full record for review, leave this section blank. If the record cited in the Application does not constitute the full record for review, identify by date and/or and document ID number(s), the additional hearings, documents, exhibits, other evidence and transcripts in the WCB's file that are relevant to the issue(s) and ground(s) raised in the application that were not cited in the application. Do not include with or attach to the Rebuttal of Application for Board Review any documents that are present in the Board's file at the time the Application was filed or this Rebuttal is filed. The Board may reject a Rebuttal by a respondent or a respondent's legal representative who attaches documents already in the Board's file at the time of the Application or the filing of this Rebuttal, in accordance with 12 NYCRR 300.13(b)(1)(ii) and (c). Do not attach or submit transcripts or audio recorded hearings, as the Board will not consider them. 15. New and Additional Evidence. If a respondent seeks to introduce new or additional evidence with the Rebuttal of Application for Board Review that was not presented before the WCLJ, the respondent must 1) state on the Rebuttal whether such evidence is attached to the Rebuttal or is in the Board's file, specifying the applicable document ID number, and 2) submit a sworn affidavit or affirmation setting forth the evidence, and explaining why such evidence could not have been presented before the WCLJ. The Board may or may not exercise its discretion to accept such evidence. If the sworn affidavit or affirmation is not submitted with the rebuttal, such new or additional evidence will not be considered by the Board Panel [see 12 NYCRR 300.13(b)(2)(v) and 300.17]. 16. Objection or Exception. If seeking to have the WCLJ decision modified, specify the objection or exception that was interposed to the ruling, and the date when the objection or exception was interposed as required by 12 NYCRR 300.13(b)(2)(ii) and (c). If the objection or exception was interposed at a hearing, the date of the hearing at which the objection or exception was interposed must be stated. If the objection or exception was interposed at a proceeding occurring off-calendar, the date of the off-calendar proceeding must be stated. 17. Increase in Attorney's Fees. When the Rebuttal is filed by the claimant's legal representative, indicate whether an increase in attorney's fees is being requested. If, yes, Form OC-400.1, Application for a Fee by Claimant's Attorney or Representative must be attached and served on the parties [see 12 NYCRR 300.13(b)(2)(v) and 300.17)]. Failure to request an additional fee in the Rebuttal of Application for Board Review and by filing a Form OC-400.1 with the Rebuttal shall result in the waiver of any additional fee. 18. Certification. The preparer must sign and date the form (also providing their name, title, telephone number and address) certifying to the Rebuttal's good faith basis in law and fact, that it had been instituted with reasonable grounds, and had been served upon the necessary parties of interest in the proof of service section. 19. Proof of Service. The Rebuttal must be served on all necessary parties of interest in accordance with 12 NYCRR 300.13(b)(2)(iv) and (c). Failure to properly serve a necessary party of interest shall be deemed defective service and the Rebuttal may not be considered by the Board. When the Rebuttal