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New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor Eliot Spitzer

Subject No. 046-172

Please do not send requests for forms to William Bryant. As of July 2007 all requests should be sent to the attention of the "Reproduction Unit".


Date: January 5, 2007

The Workers' Compensation Board has revised Form OC-400.1, Application for a Fee by Claimant's Attorney or Representative. The date of the revised form is 11-06. It is effective immediately.

Board Rule 12 NYCRR 300.17 requires that Form OC-400.1 must be filed with the Workers' Compensation Board where the amount of fee requested is more than $450, or when the form is requested by the Board. However, Form OC-400.1 may be used for any fee request. The changes made to the form are:

  • Part A - Services Rendered to the Claimant. This section has been changed from a narrative to a table format in order to elicit more detailed and specific information on the actual services rendered to the claimant and disbursements made by the attorney/representative in the performance of these services. This format will also facilitate review and evaluation of the fee request by the Board's WC Law Judges, Conciliators and Commissioners.
  • Part C - Fee Request Submitted When Claimant Is Not Present. In this section, information was added advising the claimant how he/she may object to the amount of the fee that is being requested or appeal a decision which awarded a fee that he/she considers excessive. This section also now contains an optional Claimant's Statement, which the claimant may sign after reviewing the fee request in person with his/her attorney/representative, stating that the claimant has no objection to the fee at the time of signing.

Revised Form OC-400.1 (11-06) is effective immediately. However, the previous version of Form OC-400.1 dated 1-04 may be used until March 1, 2007. After that, only the 11-06 version will be accepted.

Master copies of Form OC-400.1 and other common Board forms may be obtained by downloading the specific pdf file copy from the Board's web site ( under the heading Common Forms, or by writing or faxing the Board at:

NYS Workers' Compensation Board - Attn: Mr. William Bryant
100 Broadway-Menands, Albany, NY 12241
FAX: (518) 486-3515

Thank you for your cooperation.


Donna Ferrara