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Workers’ Compensation Board

New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo


Subject No. 046-1211

Attachment for Stipulated Agreements on Certain Schedule Losses of Use

Date: October 4, 2019

The New York State Workers’ Compensation Board accepts written stipulations when an injured worker is represented, and considers oral and written stipulations at a hearing, under Rule 12 NYCRR 300.5. The Board also receives requests for proposed findings, which are issued under Rule 12 NYCRR 312.5 (collectively referred to as “stipulations”).

The Board has developed a Schedule Loss of Use (SLU) Stipulation Attachment to be used in certain situations where the parties have agreed to resolve permanency with an SLU payment despite indications that an established non-schedule site may have residual permanent impairment. If the medical evidence shows that the non-schedule site(s) or condition(s) are resolved with no permanent impairment, the stipulation shall so indicate, without needing the Attachment.

The SLU Stipulation Attachment must be used if any of the following exist:

  • Where there is no medical report from either party regarding permanency to the established non-schedule site(s) or condition(s), the SLU Stipulation Attachment is required.
  • Where the Board file contains affirmative medical evidence of permanency to the established non-schedule site(s) or condition(s), the SLU Stipulation Attachment is required.
  • Where the medical reports of the parties differ on whether there is permanency to the established non-schedule site(s) or conditions, the SLU Stipulation Attachment is required.

When the SLU Stipulation Attachment is required, the language of the stipulation must contain the following sentence: “The Stipulation Attachment is incorporated by reference into the terms of [this Stipulation-or-these Proposed Findings] as if fully set forth herein.”

The SLU Stipulation Attachment is to be filled out and signed by the injured worker, and a separate section is to be signed by the injured worker’s legal representative. Original signatures are required. The SLU Stipulation Attachment must be sent to the Board together with the fully signed stipulation; otherwise, it will not be processed. Completed stipulations submitted under Rule 300.5 are reviewed by a Workers’ Compensation Law Judge. If rejected on the merits, a hearing will be scheduled.

The Board has created a Frequently Asked Questions document that answers questions about the SLU Stipulation Attachment. A link to the document is placed below. Injured workers should review the document before answering the questions on the SLU Stipulation Attachment, and attorneys should discuss all aspects of the SLU Stipulation Attachment with their client.

For more information, please see:

 

Clarissa M. Rodriguez
Chair