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Glossary of WCB Terms

Workers' Compensation Forms for
Attorneys and Licensed Representatives

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader Link to External Website 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.

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


Popular Forms

 

Common Forms for Attorneys and Licensed Claimant Representatives
Form Number /
Version Date
Form Title Who Files Where to File When to File
C-32 (11/09) Settlement Agreement,
Section 32
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 (1/12)

[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-1C (10/12) 丧失赚取收入能力职业数据表
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.

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