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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor David A. Paterson

Subject No. 046-434

Modifications to Board Forms RB-89,
RB-89.1, RB-89.2, and RB-89.3

Date: November 10, 2010

The Board has modified Board Forms RB-89, RB-89.1, RB-89.2 and RB-89.3 (cover sheets for applications for review and rebuttals to applications for review) to make them easier to complete.

On the reverse side of each form, the Affirmation and Affidavit concerning service have been changed so that the parties can identify the method of filing with the Board and the method of service on the parties. The Board's designated fax number and e-mail address were added to this section to ensure that the proper ones are used.

In addition, a checkbox for "ATF Deposit" was added to the list of issues on Form RB-89, Cover Sheet, Application for Review, and Form RB-89.2, Cover Sheet, Application for Reconsideration / Full Board Review. The title of Form RB-89.2 was changed from "Application for Full Board Review" to "Application for Reconsideration / Full Board Review" as that title better represents the applications being filed by the parties when review of a Memorandum of Decision filed by a Board Panel is requested.

The revised forms (all dated 6-10) are available on the Board's website under Forms. The Board encourages parties to begin using the new forms as soon as possible.

As a reminder, parties may file these forms and other materials with the Board by fax (1-877-533-0337) or by electronic mail ( Both options provide the filer with the date and time of receipt by the Board, and offer a convenient, less costly way to file.


Robert E. Beloten