State of New York WORKERS' COMPENSATION BOARD RENEWAL APPLICATION FOR LICENSE TO APPEAR ON BEHALF OF CLAIMANT under Section 24-a of the Workers' Compensation Law & Rules with respect to granting Without Fee Licenses to Representatives of Claimants. CHECK ONE: With Fee Applicants failure to disclose fully and accurately any fact or information called for by any question may result in the denial of the application for a license, or, if applicant shall have been licensed before the discovery thereof, in the revocation of his/her license. 1. Name (first, middle, last) Have you ever been known by any other name? If yes, state other name(s): Yes No 2. Home address(es) during past three years (enter present address first): Street, City, State From To Home Telephone Number (_______) __________________________ 3. Business or Occupation during past 3 years (including self-employment). Give present business first: From To Employer Address Salary Telephone No. during regular business hours (_____) _____________ Fax No.: (_____) _____________ 4. Which address and telephone number would you prefer to have appear on the Board's list of licensed representatives? (Check one only) Residence Business 5. Detail any continuing education or special training in connection with practice before the Workers' Compensation Board undertaken since you last submitted application? 6. a. Have you any other license, certificate, or authorization to practice a trade or profession? Yes b. Have you been admitted to the Bar as an attorney (or its equivalent) in any state, territory or Yes No dependency of the United States or any foreign country? If you answered Yes to either a. or b. above, give details: OC-401.1R (2-12) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com No 7. Since your last application for license under this section: a. Have you had a license, certificate, or other authorization to practice a trade or profession revoked, suspended, or subject to other disciplinary action? Yes No b. Have you been disbarred, or has your license to practice law been revoked or suspended? Yes No NA c. Have you been convicted of a crime? Yes No d. Are there any criminal charges now pending against you? Yes No If you answered Yes to either a, b,c or d above, attach a statement giving all details. 8. Do you have any arrangement with any health care provider(s) in order to facilitate handling of workers' compensation claims? Yes No If Yes, give details: 9. Do you have any arrangement with any labor organization regarding representation of their members in workers' compensation claims? Yes No If Yes, give details: 10. Approximately how many claims have you handled before the Workers' Compensation Board (including WCLJ and Board Parts) during the last completed calendar year? 11. Do you own any stock in an insurance company? Yes No If Yes, give details: 12. State in detail your income and expenses for the last completed calendar year as licensed representative or related in any way to workers' compensation: a. INCOME: 1. Total fees approved by WC Law Judges or Board: 2. Other income (itemize): 3. Total income for the calendar year 20 b. EXPENSES: 1. Rent, light, heat, paper, postage, telephone, etc.: 2. Employees: (Give name, address, duties, length of employment and salary of each): Total Salaries......................................................................................... 3. Itemize and explain payments to employees other than fixed salaries: Total additional payments to employees............................................... 4. Itemize and explain other payments for personal services: Total additional payments for personal services.................................... 5. Other miscellaneous expenses.......................................................... 6. Total expenses for the calendar year................................................. OC-401.1R (2-12) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com State of New York ) ss: County of ________________________) ________________________________________________, being duly sworn, deposes and says that I am the applicant; that I have duly read and signed the foregoing application; that all the matters contained herein are true, excepting as to such matters therein stated to be alleged on information and belief and those matters I believe to be true. In addition, I hereby authorize duly designated employees of the Workers' Compensation Board to make inquiry into and obtain disclosure of any information required to obtain verification of any statement made in this application. ____________________________________________ Signature of Applicant Sworn to before me this ________day of _______________ 20____ ___________________________________ Notary Public NOTARY'S STAMP OC-401.1R (2-12) Page 3 American LegalNet, Inc. www.FormsWorkFlow.com