State of New York - Workers' Compensation Board Claimant's Name Case Number q WCB q DB q Discrimination Note: A separate Affirmation or Affidavit is required for each Case Number. Affidavit must be notarized. SECTION 110-a AFFIRMATION I, __________________________________________________________ do hereby affirm that I am an attorney, that I have been retained to represent q claimant q insurance carrier q employer _________________________________________ in the case identified above, and that to access such case file would not be in violation of Workers' Compensation Law Section 110-a. __________________________________ __________________ SIGNATURE DATE SECTION 110-a AFFIDAVIT I, __________________________________________________________, am: (CHECK ONE) q A licensed representative retained to represent the qclaimant qinsurance carrier qemployer _______________________________________in the case identified above. q An employee of the law firm ___________________________ retained to represent the q claimant q insurance carrier q employer ________________________________in the case identified above. q An employee of the insurance carrier _____________________________ in the case identified above. Accessing this case file would not be in violation of Workers' Compensation Law Section 110-a. ________________________________________ _____________________ SIGNATURE DATE Sworn to before me this ________________ day of ___________________, 20________ ____________________________________ Notary Public Proper and full execution of this form entitles the signee to view and print pages from this case file from this day forward. This does not permit the signee to become a Party of Interest to this case file, or to receive notices. OC-110A.1 (12-03) www.wcb.state.ny.us American LegalNet, Inc. www.USCourtForms.com