Skip to Content

Site Navigation

WCB Home Page
Change Font Size
Glossary of WCB Terms
New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor David A. Paterson


Subject No. 046-292

Revised Form C-3, Employee Claim; New Form OC-400.5, Attorney/Representative's Certification of Form C-3 OR C-7

Date: March 5, 2009

Board Rule 12 NYCRR §300.37 provides, in part:

  • (d) (1) If the claimant has retained a legal representative at the time the Employee Claim form is filed with the Board, the legal representative shall file with the Employee Claim form:
  • (i) a written certification, signed by the legal representative, that to the best of the legal representative's knowledge, information and belief, formed after an inquiry reasonable under the circumstances, the allegations and other factual matters asserted on the Employee Claim form have evidentiary support or if specifically so identified, are likely to have evidentiary support after a reasonable opportunity for further investigation or discovery;

To facilitate the legal representative's filing of this certification, Form C-3, Employee Claim, has been revised to include the required certification language, the representative's signature and his/her identifying information at the end of the form, below the claimant's signature. Revised Form C-3 (3-09) is effective immediately and is available on the Board's website or at any Board office.

If the claimant has already filed Form C-3 prior to retaining a legal representative, a certification still must be filed. Board Rule 12 NYCRR §300.38 provides, in part:

  • (d) Subsequent retention of legal representative. If a claimant retains a legal representative after a claim is indexed or after the carrier files a form to controvert the claim when the claim is not indexed, the legal representative shall, within five days thereof, file with the Board and serve on all other parties a notice of retainer on the form prescribed by the Chair together with:
  • (1) An Employee Claim form, if not previously filed, or the legal representative's certification of a previously filed Employee Claim form or, if the previously filed form is incomplete, incorrect or in need of supplementation, an amended Employee Claim form and certification thereof... [emphasis added]

New Form OC-400.5, Attorney/Representative's Certification of Form C-3 or C-7, is the certification to be used in instances where a representative has been retained subsequent to the filing of Form C-3 by the claimant, and the previously filed Form C-3 is, in his/her judgment complete, correct and not in need of supplementation. New Form OC-400.5 (3-09) must be filed with the Board within 5 days after the representative is retained and copies must be served on all parties in interest. The form is effective immediately and is available on the Board's website or at any Board office.

CERTIFICATION OF FORM C-7, NOTICE THAT RIGHT TO COMPENSATION IS CONTROVERTED

Board Rule 12 NYCRR §300.38 also provides that a notice of controversy (Form C-7)

  • …must contain a written certification signed by the insurance carrier, or if represented, by its legal representative, that to the best of his or her knowledge, information and belief, formed after an inquiry reasonable under the circumstances that the allegations and other factual matters asserted in controverting the claim or the defenses asserted have evidentiary support, or if specifically so identified, are likely to have evidentiary support after a reasonable opportunity for further investigation or discovery. If the initial certification is not signed by a legal representative, then before a legal representative may appear on behalf of the insurance carrier, the legal representative shall file and serve the required certification;

Form C-7 (9-08) contains this required certification. However, in instances where Form C-7 has been filed without the certification of an attorney or representative who will be appearing before the Board on behalf of the carrier, new Form OC-400.5, with Box 2 completed, must be filed with the Board before any such appearance, and copies served to all other parties in interest.

Thank you for your cooperation.

 

Zachary S. Weiss
Chair