Fill and Sign the New York Priority Form

                                                                                              , if claimant's address shown above is new. Claimant not working and not receiving Workers' Compensation. Carrier unilaterally reduced/suspended payments W.C. Law Judge Continued/Adjourned Case until Other (Specify):                                          Hearing Set                  YE S NO 100 Broadway State Office Building State Office Building Menands 44 Hawley Street 1 80 Livingston Street1 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 REQUEST FOR PRIORITY HEARING SUBMIT THIS FORM IN DUPLICATE TO THE DIRECTOR OF CLAIMS (NYC) OR THE DISTRICT ADMINISTRATOR IN THE OFFICE WHERE THE CASE IS PENDING ANSWER ALL QUESTIONS FULLY ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B. Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. District Office Where Case is Pending Name Address to which notices should be sent (Give Number and Street, City, State, and Zip Code) 6. Injured Social Security No. Apt. No. Person 7. Employer 9. Carrier 9. Attorney or Atty/Rep. I.D. No. if any. Representative R 10. WILL THIS BE THE FIRST HEARING IN THIS CASE? Check here 11. - Reason for This Request Hearing overdue. Print Name Title Telephone No. & Ext. Signed Dated For WCB Use Only This form may only be used to request a hearing before a W.C. Law Judge in an open case. BY Dat e C-89.3 (9-91) CK0444 10- 97 I