Fill and Sign the Fee Attorney Form

                                         • attomeylrepresentative, request a fee of $                         100 Broadway State Office Building State Office Building Menands 44 Hawley Street 1 80 Livingston Street 1 25 Main Street 175 Fulton Avenue 130 Main Street W. 935 James Street ALBANY 12241 BINGHAMTON 13901 BROOKLYN 11248 BUFFALO 14203 HEMPSTEAD 11550 ROCHESTER 14614(716) 238-8300 SYRACUSE13203 (51 8) 474-6674 (607) 721-8356 (718) 802-6600 (71 6) 847-3158 (516) 560-7700 (315) 423-2932 STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUTDISCRIMINATION. APPLICATION FOR A FEE BY CLAIMANT'S ATTORNEY OR REPRESENTATIVE in accordance with Board Rule 12 NYCRR 300.17 Unless specifically requested by the Board, this form is required only where the amount of the fee requested is more than $450.00. * TO THE CLAIMANT: IF YOU DID NOT OR WILL NOT ATTEND THE HEARING AT WHICH THIS FEE REQUEST IS SUBMITTED TO THE BOARD, SEE SECTION C, ITEM 6 ON REVERSE. WCB Case No. Claimant's Name Claimant's Social Security Number Representative's Identification Number, If Any Date Retained Amount of Fee Previously Received, If Any / for the following services rendered in the above case. A. SERVICES RENDERED TO THE CLAIMANT 1 . List dates of hearing you attended with a short summary of the assistance rendered, all services performed at each hearing. (Use additional pages if necessary.) 2. List other assistance rendered to claimant: 3. List disbursements actually incurred: OC-400.1 (11- 96) Continued on reverse Yes No List previous Has the claimant to your knowledge any other attorney or representative?       Name       Address       Name                   I affirm that a copy of this application was mailed or otherwise delivered to the claimant on       At the hearing on             I I requested or will request a fee of $                                                 B. SUBSTITUTION OF ATTORNEY/REPRESENTATIVE 4. If yes, have you served Notice of Substitution upon the former attorney or representative? attorneys and/or representatives. Address. 5. What arrangement have you entered into with the other attorneys or representatives who have preceded you? C. FEE REQUEST SUBMITTED WHERE CLAIMANT IS NOT PRESENT AT HEARING TO THE ATTORNEY/REPRESENTATIVE Important: Where the claimant is not present at the hearing which this fee is requested, the attorney/representative must complete item 6 below and immediately mail a copy of this Application for Fee to the claimant. Where the attorney/representative knows in advance that the claimant will not be present at the hearing, the claimant's copymay be mailed in advance. Date * 6. TO THE CLAIMANT: for representing you. The Workers' Compensation Board will render a decision on my request 1 5 days after this fee application is mailed to you or on the date of the hearing, whichever is later. The fee approved will bededucted from your award and paid directly to me by the insurance company or employer. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. Signature of Attorney I Representative Date Submitted Address of Attorney / Representative Telephone No. Date Amount of Fee Approved W.C- Law Judge's Initials OC-400.1 (11-96) Reverse