STATE OF NEW YORK - WORKERS' COMPENSATION BOARD REQUEST FOR FURTHER ACTION BY LEGAL COUNSEL This form is for use by claimant's attorney or licensed representative ONLY. Unrepresented claimants should use Form RFA-1W or ask for Board assistance. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. WCB CASE NO. 2. CARRIER CASE NO. (if known) 3. DATE OF INJURY mm dd yy NAME Check if new address: 4. CLAIMANT ADDRESS TO WHICH NOTICES SHOULD BE SENT APT. NO. 5. EMPLOYER (at time of injury) 6. CARRIER 7. ATTORNEY OR LICENSED REP. 8. INSTRUCTIONS: The claimant seeks Board action regarding the claim identified above for the following reasons (check all that apply). Please note that the required documentation identified below must be attached to the form and submitted to the Board or must be referenced in the space provided below** (by date, name or title of document, and form ID) if it is already in the Board's electronic file. This form must be mailed, faxed or e-mailed to the Workers' Compensation Board. (See mailing and e-mail filing addresses on reverse side). Compensation: . a. Payments have been suspended or reduced on . b. Payments should be suspended as claimant returned to work at full wages on . (documentation of medical disability c. Payments should be adjusted as claimant is working at reduced earnings as of and current earnings required) d. Payments should be adjusted as claimant has concurrent employment. (documentation of weekly gross pay preceding injury and statement from second employer regarding lost time required) e. Payments should begin as claimant is not working as of . (medical documentation indicating disability required) and now seeks benefits. f. Payments should be resumed as claimant has been released from incarceration on (medical documentation indicating disability and release from custody documentation required) g. Payments have not been paid as directed by Decision filed on . Payments have not included payment of the attorney/licensed representative's fee of $ directed by Decision filed h. on . Medical Issues: i. Claimant's medical condition has changed. (medical documentation indicating change required) j. Claimant's request for medical treatment has been denied or has not been addressed. (documentation indicating denial of request for medical treatment required. Please use Form MG-2 for variance denials.) k. Claimant's disability is now permanent. (medical Form C-4.3, Doctor's Report of MMI/Permanent Impairment required) Check this box if the claimant was under 25 years of age at time of accident. Check this box if the claimant accepts the carrier's opinion on the severity of disability/loss of use. l. Claimant's request for medical and transportation reimbursement has been denied or not addressed. (receipts and Form C-257 required) Other: m. Parties have entered into a stipulation. (Form C-300.5 or written stipulation required) n. Parties have reached an agreement and seek a Proposed Conciliation Decision. (Form C-312.5 or proposed findings required) o. Claimant has discontinued or settled a lawsuit pertaining to the accident/injury of this claim. (documents indicating discontinuance, settlement, or closing statement required) p. Claimant has new or requested documentation regarding (documents required) q. Other (explain fully in the space provided below.) **Document reference information (date, name/title,form ID): I certify that this request for Board action is based upon reasonable grounds, has been submitted with my client's consent, and that this form with attachment(s) has been provided to the opposing party(ies). I also certify that (check one box below): I have discussed the issue(s) above with the opposing party(ies) or its representative(s) (give name of person contacted ) on (date) and that: (check one) no settlement of the issue(s) could be reached. settlement of the issue(s) was reached (documentation required ). on (date ) to discuss the issue(s) above, that I I have attempted to contact (name) have waited a reasonable time for a response, but that no discussion was forthcoming. CERTIFIED BY (Please Print Name) ATTY/REP ID NO. mm DATE PREPARED dd yy AREA CODE TELEPHONE NUMBER R An attorney/licensed representative fee is requested and Form OC-400.1 has been submitted. RFA-1LC (5-11) SEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO American LegalNet, Inc. www.FormsWorkFlow.com To the Claimant's Representative - General Information On Using This Form You may file this form with the Workers' Compensation Board when you want the Board to take a specific action in your client's case, or if you need to alert the Board to any problem or situation that is affecting your client's case. Many of the most frequently requested actions/situations are contained in Section 8. These are categorized as compensation issues (items a. through h.), medical (items i. through l.), or other issues (items m. through p.). However, you are not limited to those listed. Check all that apply and/or add additional information or explanation in the space provided (q). If an attorney/licensed representative fee is requested, submit Form OC-400.1. Complete the identifying information at the top of Form RFA-1LC and send the form, WITH ALL APPLICABLE EVIDENCE ATTACHED, to the Workers' Compensation Board (see address below). he Board will contact you and all parties when it takes action on your client's case. YOU MUST CERTIFY THAT YOU HAVE DISCUSSED THE ISSUE(S) OR ATTEMPTED TO CONTACT THE CARRIER/EMPLOYER AND HAVE BEEN UNABLE TO SETTLE THE OUTSTANDING ISSUE(S). YOU MUST SEND A COPY OF THIS FORM TO YOUR CLIENT, THE INSURANCE CARRIER(S), OR DIRECTLY TO THE EMPLOYER OR ITS THIRD PARTY ADMINISTRATOR IF THE EMPLOYER IS SELF-INSURED. Additional information about the Board, including information about Board forms, is available at the Board's web site: www.wcb.ny.gov. If you would like on-line access to your client's case, you can register for eCase using the registration instructions available on the Board website under the eCase link. ADDITIONAL INFORMATION Upon the submission of this form with the applicable documentary evidence, the Board will take immediate action to advance your client's claim toward resolution. Some of these actions include, but are not limited to the following: - Proposing an Administrative Determination An Administrative Determination (AD) is a decision concerning your client's claim rendered by the Board. All the evidence in your c