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Request For Further Action By Legal Counsel
ERFA-1LC

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

ATTENTION: Please read these Instructions before completing and submitting the ERFA-1LC.


If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

This form is for use by claimant's attorney or licensed representative ONLY. Unrepresented claimants should use Form RFA-1W or ask for Board assistance.

Required items are indicated by an *.

Case Information - All communications should refer to these numbers
Claimant Information
   
Employer Information (at time of injury)
Insurer Information
Attorney or Licensed Representative Information
Compensation/Medical Issues/Other
INSTRUCTIONS
The claimant seeks Board action regarding the claim identified above for the following reasons (check all that apply). Please note that the required documentation identified below must be attached to the form and submitted to the Board or must be referenced in the space provided below** (by date, name or title of document, and form ID) if it is already in the Board's electronic file.

Compensation:

(medical documentation indicating disability required)
 
(documentation of medical disability and current earnings required)
(documentation of weekly gross pay preceding injury and statement from second employer regarding lost time required)
and now seeks benefits.
(medical documentation indicating disability and release from custody documentation required)

Medical Issues:

(medical documentation indicating change required)
(attach PAR denial) Review by WCB Adjudication can only be requested if:
 
(attach any documents that show why the denial was incorrect.)
(attach "Notice of Resolution" regarding treatment.)
(attach Form C-4.3, Doctor's Report of MMI/Permanent Impairment required)
 
(receipts and Form C-257 required)

Other:

(Form C-300.5 or written stipulation, Form C-312.5 or proposed findings or Form C-32 required)
(documents indicating discontinuance, settlement, or closing statement required)
(documents required)


Sign
I certify that this request for Board action is based upon reasonable grounds, has been submitted with my client's consent, and that this form with attachment(s) has been provided to the opposing party(ies).
* I also certify that:

Certified By

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

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