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 web site.
After the form opens in your browser, you may complete the form by typing information on the form before you print it.
IMPORTANT: 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.
If you require assistance with completing these forms, please contact your local WCB District Office.
The Workers Compensation Board (WCB) has scheduled the Licensed Representative Exam for Thursday, June 12, 2014 at 9:30 AM [arrival required by 8:30 AM] at the WCB office located at 328 State Street, Schenectady, New York. Depending upon the number of applicants, it may also be held at a second WCB office located at 100 Broadway, Menands, New York. Please see the Licensed Representative Examination Guide for further details.
Please keep checking this site for any further details or updates (including any updates related to date/time/location).
Applicants seeking a license to represent claimants pursuant to Section 24-a of the Workers' Compensation Law, or to become a third-party administrator (TPA) to represent self-insured employers and/or insurance carriers should complete Form OC-409 and submit it to the Licensing Office at 328 State Street, Schenectady, NY 12305-2318, along with a $100 check or money order payable to the "Chair, Workers' Compensation Board", with each application. Complete applications accompanied by the required fee are due by close of business Wednesday, April 30, 2014.
|Form Number / Version Date||Form Title||Who Files||When to File|
|Initial Application to Take License Representative Exam||This form is to be completed by individual taking exam.||Complete applications accompanied by the required fee are due by close of business Wednesday, April 30, 2014.|
|Form Number /
|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|
|Form Number /
|Form Title||Who Files||Where to File||When to File|
|C-32 (11/09)||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-32.1 (1/11)||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, Settlement Agreement.|
|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-300.5 (7/97)||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-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 (1/11)||Notice of Retainer and Substitution||Attorney/ Licensed Representative||Workers' Compensation Board, copy to all claimant's health providers.||Immediately upon being retained.|
|OC-400.1 (1/11)||Attorney/ Representative's Application for Fee||Attorney/ Licensed Representative||Workers' Compensation Board, copy to claimant.||When fee of more than $450 is requested.
If claimant not present, he/she must be advised of 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-406 (5/08)||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.|
|PH-16.2 (3/14) Paper Version
[PH-16.2 On-line 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 (C-7) cases.|
|RB-89 (1/11)||Cover Sheet - 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 (1/11)||Cover Sheet - 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 (1/11)||Cover Sheet – 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 (1/11)||Cover Sheet – 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 (5/11) Paper Version
[RFA-1LC On-line Submission]
|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. REPLACES FORM RFA-1.|
[VDF-1 On-line 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.|
|VDF-1S (10/12)||Pérdida de la capacidad de generar ingresos Formulario de datos profesionales|
|VDF-1H (10/12)||Pèt Mwayen pou Touche Salè Fòm Enfòmasyon Pwofesyonèl|
|VDF-1I (10/12)||Perdita della capacità di guadagno del salario Modulo per i dati professionali|
|VDF-1K (10/12)||임금획득능력의 상실 직업 데이터 양식|
|VDF-1P (10/12)||Utrata możliwości zarobkowania Formularz danych na temat pracy zawodowej|
|VDF-1R (10/12)||Потеря трудоспособности Бланк для информации о профессиональном образовании и трудовой деятельности|
|W-32R (3/11)||WAMO Settlement Agreement-Section 32||Parties of Interest||To obtain WAMO signature, mail to:
Waiver Agreement Management Office (WAMO)
NYS Workers' Compensation Board
328 State Street Schenectady, NY 12305-2318
When all POIs have signed, mail to the WCB District Office.
|Special Disability Funds must have all or partial liability. May be filed at any time during an open and pending case, and may cover any and all issues.|