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".

REVISED FORM OC-400.1
APPLICATION FOR A FEE BY CLAIMANT'S ATTORNEY OR REPRESENTATIVE

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 (www.wcb.ny.gov) 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
Chair