Fill and Sign the Ny Request Form 497321893

Yes No Yes No                                                                                                                                                        IF CLAIMANT'S ADDRESS SHOWN ABOVE IS NEW. a. contends that continuing payments should be: c. has evidence of voluntary removal from the labor market. d. requests referral to conciliation (WCL 25(2-b) and Rule 312) Suspended Reduced to $       evidence of change in medical condition pursuant on the issue of             payroll evidence warranting a rate modification e. requests resolution by administrative determination (Rule 313) f. has evidence relating to disqualification under WCL 114-a. g. requests relief under WCL 15(8), 25-a or 14(6). b. in response to a request to reopen, contends under payments have resumed from             at a weekly rate of $       h. has new or requested evidence. i. has payroll evidence relating to reduced earnings. j. has evidence of the settlement of a third party action. k. requests a resolution regarding schedule loss of use payments have resumed as indicated above without the right to compensation is not disputed, but: no payments are due. Necessary medical treatment payments have not begun (explain below). the right to compensation is disputed (explain below). l. other (please specify in the space provided below.)             R carrier CARRIER'S/EMPLOYER'S REQUEST FOR FURTHER ACTION 4. DATE OF INJURY 6. DISTRICT OFFICE ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 3. CARRIER CODE 4. DATE OF INJURY 5. SOCIAL SECURITY NO. 6. DISTRICT OFFICE 1. WCB CASE NO. 2. CARRIER CASE NO. m m d d y y NAME ADDRESS TO WHICH NOTICES SHOULD BE SENT APT. NO. 7. CLAIMANT 8. EMPLOYER 9. CARRIER 10. ATTORNEY OR ATTY/REP I.D. NO. LICENSED REP. CHECK HERE REASON FOR THIS REQUEST (Check all that apply - use item l. for explanation or additional information) 11. CARRIER/EMPLOYER per week based on: to Rule 300.23. under Rule 300.23. ATTACH MEDICAL OR PAYROLL EVIDENCE SUPPORTING YOUR POSITION. IFMEDICAL EVIDENCE WAS PREVIOUSLY SUBMITTED, IDENTIFY IT IN ITEM l.BELOW BY DATE, DOCTOR'S NAME AND FORM ID, IF ANY. Rule 300.22(e) that: to . prejudice and without admitting liability (WCL 21-a). is authorized. or facial disfigurement. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. IF MEDICAL EVIDENCE WAS PREVIOUSLY SUBMITTED,IDENTIFY IT BY DATE, DOCTOR'S NAME AND FORM ID, IF ANY, IN THE SPACE PROVIDED ABOVE . 12. Have the above issues been resolved by agreement? If Yes, please attach documentation. If No, have you attempted to resolve the issue(s) checked above with the other parties? I hereby certify that a copy of this form with attachment(s) was submitted to the other party(ies) in this case in accordance with the instructions above. PREPARED BY (Please Print Name) DATE PREPARED m m d d y y AREA CODE TELEPHONE NUMBER This form is submitted by self-insurer RFA-2 (12-04) SEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO TO THE CARRIER/EMPLOYER This form may be filed by the insurance carrier or employer in a workers' compensation case when it wants the Workers' Compensation Board to take action in the case. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. A copy of this form must also be sent to the claimant, and his/her representative, if any. ITEM 11a replaces Form C-22b. If item 11a is checked, a copy must be filed with claimant's attending doctor. (See additional information below regarding item 11a). ITEM 11b replaces Form RB-679. If item 11b is checked, this form must be filed within 25 days after receiving an application to reopen a case previously established and designated closed or no further action by the Board. If the employer becomes aware that a claimant whose case has been designated closed or no further action by the Board has begun to lose additional time, the employer or carrier may begin temporary payments of compensation immediately. ITEM 11d replaces Form CB-8. All uncontested claims where the expected duration of benefits is 52 weeks or less shouldbe resolved in conciliation [Rule 312.2]. ITEM 11e - All uncontested claims involving only temporary minor injuries should be resolved through administrative determination [Rule 312.2[a]]. TO THE CLAIMANT If you have any questions regarding the action being requested by the carrier/employer, please contact the nearest office of the Board. If you have retained legal counsel to represent you, you may contact him/her for assistance. Please remember to always use the WCB Case Number shown on the other side of this form when corresponding with the Board. Regarding Item 11a . - Board Rule 12 NYCRR 300.23 This notice (item 11a) replaces Form C-22b for the purpose of notifying the Board of the carrier/employer's intention to reduce orsuspend the claimant's payments in accordance with Board Rule 12 NYCRR 300.23. This notice may be filed in any case where there has been an award and a direction for continuation of payments and evidence ispresented to support the suspension of payments or reduction in rate. The Board, upon receipt of this notice and attachments, may either schedule a WC LAW JUDGE HEARING on this issue within 20 daysduring any period in which regular hearings are scheduled, or refer the matter to the Office of Appeals for a determination of whether areopening is warranted. In the event that the Office of Appeals directs that the case be reopened, a WC Law Judge Hearing will bescheduled in an expeditious manner. IF THE REQUIRED DOCUMENTATION IS NOT ATTACHED, THE CASE WILL NOT BESCHEDULED FOR A HEARING. Cases at hearing points which do not have regularly scheduled hearings within 20 days may be scheduled at another hearing point. At the time a WC Law Judge hearing is held, either immediately after the Board's receipt of this notice and attachments or at the directionof the Office of Appeals, the WC Law Judge will consider all available evidence and decide whether or not payments may be suspendedor reduced. PAYMENTS SHALL CONTINUE, AS DIRECTED, until there is a determination by the WC Law Judge that such payments may besuspended or reduced. TO THE CLAIMANT - Regarding Item 11a Please read this notice and attachments carefully. If item 11a is checked, this notice means that your employer (if self-insured) or its insurance company wants to suspend or reduce your compensation payments, for the reason indicated. As explained above, your case may be scheduled for a hearing on this issue. Be sure to BE PRESENT, if you disagree with your employer or his/her insurance company. If you are NOT PRESENT, the W.C. Law Judge will make a decision based on availableevidence.If your employer or his/her insurance company contends that your compensation payments should be suspended or reduced because your medical condition has improved (not because your earnings have increased), BRING TO YOUR HEARING THE MOST RECENTMEDICAL REPORT FROM YOUR DOCTOR THAT DESCRIBES YOUR CURRENT MEDICAL CONDITION. Section 114 of the Workers' Compensation Law provides, in part, that any employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who knowingly makes a false statement or representation as to a material fact for the purpose ofavoiding provision of any payment or benefit under this chapter shall be guilty of a felony. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC(800)877-1373 HEMP(866)805-3630 HAUP(866)681-5354 PEEK(866)746-0552 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 RFA-2 (12-04) Reverse