Fill and Sign the Ny Dispute Form

CLAIMANT EMPLOYER CARRIER                  Yes No                                 CONTROVERTED CLAIM EXPEDITED CLAIM Has been filed Is attached Yes No Is Attached Yes No Give physician's name and date of report which gives prima facie medical evidence:       Yes No                   Completed On-going       3. Give the date when the investigation will be completed.                   If no, explain why not:       PREPARED AND SUBMITTED BY       ON BEHALF OF             / / State of New York WORKERS' COMPENSATION BOARD STATEMENT ON SPECIFIC ISSUES IN DISPUTE for Controverted and Expedited Cases THIS AGENCY EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUTDISCRIMINATION WCB CASE NUMBER CARRIER CASE NUMBER CARRIER ID NUMBER DATE OF ACCIDENT OTHER PARTIES-IN-INTEREST PLEASE ANSWER ALL QUESTIONS COMPLETELY. See reverse side for further explanation and instructions. CLAIMANT 1. Has a claim for compensation (C-3) been filed or attached to this form? 2. Has a medical report giving prima facie medical evidence been filed or is it attached to this form? (See reverse of this form for a description of ''prima facie medical evidence.'') Has been filed 3. Has this claim and/or disputed issues been discussed with the carrier/self-insured employer? If no, explain why not: 4. The issues in dispute are the following: Provide only those issues in which you are prepared to provide evidence for the Board to consider. 5. The following witnesses will provide testimony on the disputed issues. Give name, purpose of testimony, and availability. CARRIER/SELF-INSURED EMPLOYER 1. The status of the carriers/self-insured employers investigation relative to the issues in dispute is as follows: 2. If the investigation is on-going, explain why the investigation has not been completed and what further investigation is necessary. 4. List the issues in dispute upon which you are prepared to provide evidence for the Board to consider. 5. List all witnesses who will provide testimony on the disputed issues. Give name, purpose of testimony, and availability. 6. Has the claim and/or disputed issues been discussed with claimant or claimant's counsel? name and title, if any DATE claimant or carrier PH-16.2 (5-06) www .wcb.state.ny.us Statement on Specific Issues in Dispute Three sections in the Workers' Compensation Law require each party to file statements with the Board prior to the hearing as to the specific issues in dispute,- in claims wherein the carrier/self-insured employer has filed a notice of controversy (Form C-7) and in cases which the Board has designated as expedited. (WCL § 25(2-a)(d), 12 NYCRR 300.33(c), and 12 NYCRR 300.34(b)). For claims controverted by the carrier/self-insured employer, the Board will schedule a pre-hearing conference before a WCL Judge or Senior Attorney/Conciliator. The pre-hearing conference provides the Board with an opportunity to meet with the parties, ascertain the relevant disputed issues, simplify and limit the issues, review the witness list, and set the case on a resolution track which will allow the parties to present all relevant and probative evidence in a timely manner so that the Board can render its decision. Prior to notice of a pre-hearing conference, the parties must review their cases and perform any necessary investigation and outreach with due diligence so that the scheduled pre-hearing conference is productive. For claims in which the carrier/self-insured employer has filed a notice of controversy (Form C-7), discovery as to the threshold issues of accident or occupational disease, notice, and causal relationship (ANCR and ODNCR) employer/employee relationship, prima facie medical evidence, and coverage shall close at the end of the pre-hearing conference. Evidence not disclosed or obtained thereafter as to those threshold issues shall not be admissible unless the proponent of the evidence can demonstrate that it was not available or could not have been discovered by the exercise of due diligence prior to the For claims which the Board has designated as expedited (WCL § 25([3][d]), any and all outstanding issues in dispute should be addressed to the extent possible atone hearing. Requests for adjournments deemed not an emergency and frivolous will result in substantial penalties'' however, no penalty will be imposed upon a claimant who represents him/herself and requests an adjournment. This statement on the specific issues in dispute must be filed with the Board by mailing it to the nearest district office address listed below at least ten (11 0) days before the pre-hearing conference for controverted (C-7 cases) or within twenty (20) days after the Board has ordered the case expedited. Important Information for Claimants, Attorneys, Licensed Representatives, Insurance Carriers, and Self-insured Employers Claimants Who Represent Themselves For claims that have not been accepted by the carrier or self-insured, the Board may, for good cause shown, excuse a claimant who represents him/herself from filing this form (12 NYCRR 300.33[f][3]). The claimant, however, must file aclaim for compensation (Form C-3) and a prima facie medical report (Form C-4) or other medical report from his/her doctor giving all of the following: (1) a history of the accident or occupational disease, (2) diagnosis, and (3) an opinionas to the causal relationship of the medical condition to the injury. Failure to file a prima facie medical report will result inthe Board's taking no further action on the claim until such report is received.For claims which have been expedited by the Board, the claimant must file this form. When filing this form with the Board, remember to send a copy to the carrier or self-insured employer. Claimants Represented by Counsel Submission of this form to the Board and service upon all parties is required pursuant to WCL § 25(2-a)(d) and 12 NYCRR 300.33(e) or 12 NYCRR 300.34(b). Failure to file a completed form along with the required attachments withinthe time specified may render certain evidence inadmissible and/or result in the Board's designating the case as one inwhich it can take no further action. Carriers/Self -insured Employers Submission of this form to the Board and service upon all parties is required pursuant to WCL § 25(2-a)(d) and 12 NYCRR 300.33(c) or 12 NYCRR 300.34(b). Failure to file a completed form along with the required attachments withinthe time specified may subject the employer or insurance carrier to a penalty pursuant to WCL § 25 (3)(e), and/or rendercertain evidence inadmissible. Failure to properly complete this form may subject the carrier/self-insured employer to apenalty for dilatory tactics or unjustified lack of preparedness (WCL § 25[3][c]). WORKERS' COMPENSATION BOARD DISTRICT OFFICES WORKERS' COMPENSATION BOARD DISTRICT OFFICES DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC(800)877-1373 HEMP(516)560-7700 HAUP(631)952-6000 PEEK(914)788-5775 100 Broadway State Office Building Statler TowersMenands 44 Hawley Street 107 Delaware Ave. ALBANY 12241 935 James Street BINGHAMTON 13901 BUFFALO 14202 ROCHESTER 14614 (866) 750-5157 (866) 211-0645 (866) 211-0644 SYRACUSE 13203 (866) 802-3604 (866) 802-3730 PH-1 6.2 (5-06) Reverse