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Workers’ Compensation Forms Attorneys and Licensed Representatives

Forms

Completing Forms

If you require assistance with completing these forms, please contact us.

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it. If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. If you still have trouble with the form, please email the Board's Forms Department.

Multi-page Forms
Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.

Current Versions of Forms
WCB periodically releases new versions of certain forms to obtain additional information, streamline processing, and/or make it easier to complete the form. These changes are often extensive, and it is important for all stakeholders to use the same form so that information is consistent. As such, WCB may announce that it will not accept older versions of an updated form after a certain date. The table below has the most recent version of each form, and where older versions are no longer accepted, includes the notation "Only current version accepted."

Original Signature Requirement

COVID-19 Response: Original Signature Requirement Relief – March 2020

The Workers' Compensation Board does not normally accept a claimant's electronic signature on Board-prescribed forms. Due to recent increases in COVID-19 infection rates across New York State, however, as of August 16, 2021, the Emergency Relief from Signature Requirements on Listed Documents will remain in effect until further notice for the forms specifically listed in the Board's announcement: Emergency Relief from Original Signature Requirements on Listed Documents.

The Board, as standard practice, does not accept electronic signatures on Board-prescribed forms, as the Board is unable to efficiently evaluate the electronic signature process used by an insurer, health care provider, attorney, or licensed representative to ensure that the procedure complies with the New York Electronic Signatures and Records Act (ESRA) and applicable regulations. Therefore, a claimant's ink signature must be supplied when a claimant's signature is required by law.


Popular Forms


License Application Forms for Individuals wishing to be Licensed Claimant Representatives
Form Number /
Version Date
Form Title Who Files Where to File When to File
OC-401.1 (09/07) Initial Application for License to Appear on Behalf of Claimant This form is to be completed by the individual requesting a license after successfully passing the Licensed Representative Exam. Workers' Compensation Board, Licensing Bureau New Licenses
OC-401.1R (2/12) Renewal Application for License to Appear on Behalf of Claimant This form is to be completed by the individual renewing license. Workers' Compensation Board, Licensing Bureau License Renewal

Common Forms for Attorneys and Licensed Claimant Representatives
Form Number /
Version Date
Form Title Who Files Where to File When to File
C-32 (4/21) Waiver Agreement - Section 32 WCL Parties in Interest Form must be signed by all parties in interest and mailed to WCB (or presented at hearing). Agreement may be filed at any time during an open and pending case, and may cover any and all issues
C-32.1 (1/23)

Only current version accepted

Video: Settling Your Claim
Section 32 Settlement Agreement: Claimant Release Party Submitting Section 32 Settlement Agreement Workers' Compensation Board Completed and notarized Form C-32.1 must be filed along with Form C-32, Section 32 Agreement.
C-32AF (12-21) Carrier's/Self-Insured Employer's Affirmation Insurance Carrier, Self-Insured Employer or Third-Party Administrator Workers' Compensation Board Filed as an attachment to the C-32 agreement.
C-32E (7/19) Section 32 - Electronic Signature Insurance Carrier, Self-Insured Employer or Third-Party Administrator Workers' Compensation Board Filed as an attachment to the C-32 agreement.
C-32-I (6/20) Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement Parties in Interest Form must be signed by all parties in interest and mailed to WCB (or presented at hearing) Agreement may be filed at any time during an open and pending case, and may cover any and all issues.
C-35 (4-17) Extreme Hardship Redetermination Request Section 35(3) of the Workers' Compensation Law Injured Worker Workers' Compensation Board When an injured worker is requesting a redetermination due to an extreme hardship as described in Section 35(3) of the Workers' Compensation Law and has been classified with a permanent partial disability with a loss of wage earning capacity of greater than 75% and capped benefits will expire within one year.
C-300.5 (10/16) Stipulation Employee (and Attorney or Representative, if represented) and Carrier/Board-approved self-insurer Workers' Compensation Board To be used for stipulations to uncontested facts or proposed findings, pursuant to 12NYCRR 300.5.
C-300.34 (10/97) Statement of Unresolved Issues (Special Part for Expedited Hearings) Parties in Interest Workers' Compensation Board, with copies to all other parties in interest. Within 20 days after case is ordered transferred to the Special Part for Expedited Hearings.
C-312.5 (12/10) Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only) Claimant (if represented) and Carrier/Board-approved self-insurer Workers' Compensation Board In cases where the claimant is represented, this form is to be used by the parties to propose findings and awards pursuant to 12NYCRR 312.5.
OC-110AORD (7-10) Request for Judicial Order – Access to Case Files Individuals or Entities not considered parties in interest who are seeking access to case files Workers' Compensation Board As needed. This form may be submitted in person at any Board office, mailed or faxed ((877) 533-0337) to the Board.
OC-400 (1/23)

Only current version accepted

Notice of Retainer and Substitution Attorney/Licensed Representative Workers' Compensation Board, copy to all claimant's health providers. Immediately upon being retained.
An R number is required.
Request R Number
OC-400.1 (1/23)

Only current version accepted

New Fee Application Desk Aid
Application for a Fee by Claimant’s Attorney or Licensed Representative Attorney/Licensed Representative Workers’ Compensation Board, copy to the claimant. When fee of more than $1,000 is requested.

If the claimant is not present, they must be advised of the fee request, using this form, 10 days prior to awarding of fee.
OC-400.5 (6-13) Attorney/Representative's Certification of Form C-3 or Notice of Controversy Attorney/Licensed Representative Workers' Compensation Board, copy to all other parties of interest. Claimant's Attorney/Representative: Within 5 days after you have been retained by a claimant who has previously filed Form C-3 without your certification.

Carrier's Attorney/Representative: If Notice of Controversy has been filed without your written certification, OC-400.5 must be filed before you may appear on behalf of the carrier.
OC-400.17 (8/20) Attorney/Licensed Representative Request to Withdraw from Representation Attorney/Licensed Representative Workers' Compensation Board, copy to all other parties of interest. Once completed, this form is to be filed immediately.
OC-406 (1/18) Notice of Retainer and Appearance on Behalf of Employer Attorney representing employer before the Board in a no insurance, discrimination or double indemnity case. Workers' Compensation Board Immediately upon being retained.
OC-408 (10/16) Licensed Representative’s Full Disclosure of Conflict of Interest to Client Licensed Representatives of claimants, employers and carriers Workers’ Compensation Board and the client(s) of the licensed representative. Whenever the licensed representative has an adverse interest or relationship with any of the parties to a proceeding.
PH-16.2 (10/18) Paper Version


[PH-16.2 Online Submission]

Adobe Format Overview/Features
Pre-Hearing Conference Statement Claimant's Attorney or Licensed Representative; Carrier or Board-approved self-insured employer Workers' Compensation Board, with copies served on all other parties of interest. Ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04).
RB-89 (1/23) Application for Board Review Party applying for Board Review of WC Law Judge decision Workers' Compensation Board, copy to all other parties of interest. Within 30 days after notice of filing of the decision of the WC Law Judge.
RB-89.1 (1/23) Rebuttal of Application for Board Review Party rebutting application for Board Review of WC Law Judge decision Workers' Compensation Board, copy to all other parties of interest. Within 30 days after service of the application for review upon the party making the rebuttal.
RB-89.2 (1/23) Application for Reconsideration / Full Board Review Party applying for Full Board Review of Board Panel decision. Workers' Compensation Board, copy to all other parties of interest. Within 30 days after notice of filing the decision of the Board Panel.
RB-89.3 (1/23) Rebuttal of Application for Reconsideration / Full Board Review Party rebutting application for Full Board review of Board Panel decision Workers' Compensation Board, copy to all other parties of interest Within 30 days after service of the application for Full Board Review upon the party making the rebuttal.
RFA-1LC (5/22) Paper Version

Only current version accepted

[RFA-1LC Online Submission]

04/29/2022 - RFA Process Updates
Request for Further Action by Legal Counsel Claimant's Representative Workers' Compensation Board, with copy to employer's insurance carrier or directly to employer or third-party administrator if employer is a Board-approved self-insurer. The form may be filed at any time after the assembly or indexing of a claim or after the Board has indicated that no further action (NFA) will be taken.
VDF-1 (1/12)

[VDF-1 Online Submission]
Loss of Wage Earning Capacity Vocational Data Form Claimant Workers' Compensation Board, copy to insurance carrier Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

If the form you are looking for is not listed above, or in the list of Common Board Forms, please contact the Board.