If you need additional help in completing this form, contact the Workers’ Compensation Board at 1-877-632-4996.
Some of the fields on this form are hidden and will become visible based on your responses to another question.
After the Board receives your form, a non-editable PDF version of the form will appear in your web browser. The first page contains a confirmation that your form was successfully submitted to the Board and the date. It should be saved for your records. DO NOT MAIL THIS FORM TO THE BOARD.
If a confirmation page does not appear in your web browser after you submit the form to the Board, then the Board did not successfully receive the form and you will need to resubmit it.
In any claim where the Board has sent a Notice of Indexing to the parties indicating that the Board has jurisdiction over the claim, and where the Board's Electronic Case Folder (ECF) contains a Notice of Controversy (Form C-7) and a medical report referencing an injury, the Board shall send to the parties a notice of pre-hearing conference, which shall occur no later than 30 days from the Board's receipt of the notice of controversy.
This statement must be completely filled out separately by claimant's representative and the employer or carrier, and each party must file with the Board and serve the completed statement on all parties NO LATER THAN TEN DAYS BEFORE THE DATE OF THE PREHEARING CONFERENCE.
A claimant who has not retained a legal representative is not required to fill out this form. If a legal representative is retained by the claimant, and ten or more days remain before the pre-hearing conference, the legal representative is required to fill out this form. If the claimant retains a representative with less than 10 days remaining until the pre-hearing conference, the insurance carrier or employer will be able to adjourn the proceedings, which will result in a delay in a potential award of compensation and medical benefits.
All attachments to the form must be submitted to the Board with this form if they are not already in the electronic case folder. DO NOT SUBMIT ATTACHMENTS THAT ARE ALREADY IN THE BOARD'S FILE.
A. Insurance Carrier or Employer:
Failure by the insurance carrier to timely serve upon all other parties and file with the Board the pre-hearing conference statement, or the filing by the insurance carrier of a materially incomplete statement shall result in a waiver of defenses to the claim. Failure to list a witness on, or to include a copy of any document not in the ECF with the pre-hearing conference statement, which the insurance carrier had in its possession or could reasonably have obtained, shall constitute a waiver of the right to call such witness or introduce such document in the case. There shall be no waiver if the workers' compensation law judge finds, based on the affidavit of the insurance carrier's legal representative (or if the insurance carrier does not have a legal representative, by the insurance carrier) that the conduct at issue was due to good cause and the insurance carrier exercised good faith and due diligence.
B. Claimant's Legal Representative:
The legal fee of the claimant's legal representative shall be subject to a mandatory, substantial reduction for any of the following: