Can I e-sign this request?

Yes if the board accepts electronic signatures; follow ESIGN and New York ESRA guidance and include an audit trail showing signer identity and timestamp.

Is remote notarization allowed?

It depends on the board and New York rules; confirm whether RON is accepted and whether the notary must retain A/V records and journal entries.

What if an attachment is missing?

The board may return or reject the request for incompleteness; include an exhibit index and ensure each file is legible and properly labeled.

How do I correct a filed request?

Submit a supplemental filing that clearly references the original docket number and explains the correction; follow the board's amendment procedures.

Witness requirements vary; New York often requires a single witness for certain acknowledgements—verify with the board or state notary rules.

Can I use signNow to file electronically?

signNow supports secure e-signatures, audit trails, HIPAA-compliant workflows with a BAA, and integrations for document delivery, subject to the board's acceptance of electronic filings.

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New York Board Claimants Request for Further Action

New York Board Claimants Request for Further Action

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State of New York
WORKERS' COMPENSATION BOARD

CLAIMANT'S REQUEST FOR FURTHER ACTION

INSTRUCTIONS: To request Board action on a case, complete this form and submit it to your local WCB district office. See mailing addresses on the reverse side. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. You must also send a copy of this form to your employer's workers' compensation insurance carrier, or directly to your employer or its third party administrator, if it is self-insured. This form is NOT to be used to APPEAL a decision.

ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS

1. WCB CASE NO.

2. CARRIER CASE NO.

3. CARRIER CODE

4. DATE OF INJURY

5. SOCIAL SECURITY NO.

6. DISTRICT OFFICE

7. CLAIMANT

ADDRESS TO WHICH NOTICES SHOULD BE SENT

APT. NO.

8. EMPLOYER

ADDRESS TO WHICH NOTICES SHOULD BE SENT

APT. NO.

9. CARRIER

ADDRESS TO WHICH NOTICES SHOULD BE SENT

APT. NO.

10. ATTORNEY OR
LICENSED REP.

ADDRESS TO WHICH NOTICES SHOULD BE SENT

APT. NO.

ATTY/REP I.D. NO

CHECK HERE IF CLAIMANT'S ADDRESS SHOWN ABOVE IS NEW.

REASON FOR THIS REQUEST

(Check all that apply - use item o. for explanation or additional information - see reverse side for further explanation)

10. CLAIMANT

a. requests referral for Administrative
Determination/Conciliation/Hearing, as
appropriate, because (please check the
appropriate boxes below):

b. he/she has had a change of medical condition.
IF THIS BOX IS CHECKED ATTACH MEDICAL REPORT IF REPORT WAS
PREVIOUSLY SUBMITTED IDENTIFY IT IN ITEM O. BELOW BY DATE,
DOCTOR'S NAME AND FORM ID, IF ANY.

c. he/she is not working and not receiving payments.

d. his/her payments have been suspended/reduced.

e. he/she has returned to work at full wages.

f. he/she is working at reduced earnings.

g. he/she has not been paid as directed in a notice
of decision.

h. a request for medical treatment was denied or not
addressed.

i. a request for medical and transportation
reimbursement was denied.

j. he/she now has medical evidence of permanency.

k. new or requested evidence is now available.

l. claimant's representative's fee has not been paid.

m. he/she has discontinued or settled a lawsuit
pertaining to this accident/injury.

n. claimant has a change of address (please provide
new address in 6., above)

o. other (explain fully in the space provided below.)

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.

11. Have the above issues been resolved by agreement? Yes No If Yes, please attach documentation.

If No, have you attempted to resolve the issue(s) checked above with the other parties? Yes No

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

AREA CODE

TELEPHONE NUMBER

This form is submitted by claimant claimant's representative

RFA-1 (8-03) SEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO

What the New York Board Claimants Request for Further Action Is

The New York Board Claimants Request for Further Action is a formal written request used by a claimant to ask a New York administrative board or agency to take additional steps on an existing matter, such as reopening a claim, scheduling a hearing, or issuing a supplemental determination. The form documents the claimant's identity, the specific relief requested, the factual and legal basis for the request, and any supporting evidence. It is intended for use in state-administered administrative procedures and should follow the board's formatting and submission rules under New York law.

Why a Proper Request Matters

A clear, well-documented request focuses the board on the specific action sought and reduces processing delays by providing the required facts, dates, and attachments.

Who Typically Prepares and Submits This Request

The request is prepared by claimants and their authorized representatives when they need the board to take an additional procedural or substantive step on a pending matter.

Claimants or appellants filing to reopen or modify a decision; they supply facts, dates, and supporting documents for the board to act on.
Private counsel or agency representatives who draft legal justification, cite governing rules, and coordinate procedural steps with the board.
Administrative staff and paralegals who compile exhibits, verify service addresses, and track submission deadlines for timely processing.

Core Components of an Effective Request

A professional Request for Further Action clearly identifies the parties, describes the requested action, cites relevant facts or rulings, and includes verifiable attachments and contact details for efficient processing.

Heading

Reference the board docket or claim number and include a concise subject line identifying the request type and date.

Claimant ID

Provide full legal name, mailing address, phone, email, and any representative contact details to ensure accurate routing.

Requested Action

State the specific relief requested (reopen, rehearing, supplemental order) with precise language to avoid ambiguity.

Grounds

Summarize factual and legal reasons for the request, citing prior board decisions or procedural rules when applicable.

Attachments

List and attach supporting evidence (medical reports, affidavits, correspondence) with exhibit labels and dates.

Signature

Include a dated signature block for the claimant or authorized representative, and any notarization or witness details if required.

Step-by-Step: Prepare and Submit Your Request

Follow these sequential steps to assemble, verify, and submit a complete request that conforms to typical board procedures.

01

Gather Records: Collect the decision, relevant evidence, and correspondence.
02

Draft Request: State the action, grounds, and attached exhibits clearly.
03

Sign and Date: Execute the signature block and notarize if required.
04

Submit: File by the board's accepted method and retain proof of service.

How to Configure an Online Submission Workflow

Set up an electronic workflow that mirrors board requirements: required fields, attachment handling, signature capture, and confirmation delivery.

Field Validation	Make key fields mandatory to avoid incomplete submissions
Attachment Rules	Accept PDF, 300 DPI scans; limit file size per board limits
Signature Type	Specify whether simple e-signature or notarized RON is required
Notifications	Send automated confirmations to claimant and representative
Retention	Store a signed PDF and an audit trail for recordkeeping

Where and How to File Your Request

Choose the board's accepted submission channel and provide proof of service; verify whether the board accepts electronic filings under New York rules.

Board Portal: Submit via the board's online filing system when available
Email Submission: Use the official board email address if permitted
Postal Mail: Send certified mail with a return receipt where required
In-Person Delivery: Deliver to the board clerk and obtain a filing stamp

Digital Submission and Signature Considerations

Maintain a reproducible signed record and an audit trail showing signer identity, timestamps, and attached exhibits for administrative review.

E-sign Laws: Comply with ESIGN and New York ESRA
Authentication: Use email, SMS, or stronger methods per board rules
Notarization: Check if remote online notarization is permitted

Typical Timeframes and Processing Expectations

Processing times vary by board, complexity, and caseload; submit complete materials to avoid avoidable delays.

Acknowledgment Window:

Many boards provide filing acknowledgment within 10 business days

Initial Review:

Preliminary completeness review commonly takes 2–4 weeks

Decision Timeline:

Substantive action or scheduling may take 30–90 days depending on caseload

Extension Requests:

Requests for additional time are subject to board discretion

Service Proof:

Retain certified mail receipts or electronic delivery confirmations indefinitely

Risks of Incomplete or Incorrect Requests

Dismissal Risk: Request may be denied for procedural defects

Delay: Incomplete materials prolong resolution timelines

Evidence Exclusion: Late attachments may not be considered

Service Failure: Improper service can invalidate the filing

Fee Forfeiture: Nonrefundable fees may be lost in some boards

Appeal Bar: Procedural errors may limit appellate remedies

Common Preparation Mistakes to Avoid

Submitting unsigned or undated requests that require a signature block and date reduces credibility and may be returned for correction.
Failing to include the board docket or claim number results in misrouting and administrative delays that could extend processing by weeks.
Attaching unreadable scans or mismatched exhibits frustrates reviewers; label each exhibit with a unique identifier and date.
Using informal or vague language for the relief requested makes it harder for the board to grant precise action; be specific and cite any rule or prior order.

Comparing eSignature Providers for Submitting Requests

When choosing an eSignature provider for filing and recordkeeping, compare price, bulk sending, audit trails, HIPAA support, and any envelope limits that affect volume.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions and Troubleshooting

Answers to common questions about late submissions, signatures, notarization, electronic filing, and recordkeeping to help avoid processing delays.

Need help? Contact support

Can I e-sign this request?
Yes if the board accepts electronic signatures; follow ESIGN and New York ESRA guidance and include an audit trail showing signer identity and timestamp.
Is remote notarization allowed?
It depends on the board and New York rules; confirm whether RON is accepted and whether the notary must retain A/V records and journal entries.
What if an attachment is missing?
The board may return or reject the request for incompleteness; include an exhibit index and ensure each file is legible and properly labeled.
How do I correct a filed request?
Submit a supplemental filing that clearly references the original docket number and explains the correction; follow the board's amendment procedures.
Do I need a witness?
Witness requirements vary; New York often requires a single witness for certain acknowledgements—verify with the board or state notary rules.
Can I use signNow to file electronically?
signNow supports secure e-signatures, audit trails, HIPAA-compliant workflows with a BAA, and integrations for document delivery, subject to the board's acceptance of electronic filings.

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New York Board Claimants Request for Further Action

State of New YorkWORKERS' COMPENSATION BOARD

CLAIMANT'S REQUEST FOR FURTHER ACTION

REASON FOR THIS REQUEST

What the New York Board Claimants Request for Further Action Is

Why a Proper Request Matters

Who Typically Prepares and Submits This Request

Core Components of an Effective Request

Heading

Claimant ID

Requested Action

Grounds

Attachments

Signature

Step-by-Step: Prepare and Submit Your Request

How to Configure an Online Submission Workflow

Where and How to File Your Request

Digital Submission and Signature Considerations

Typical Timeframes and Processing Expectations

Acknowledgment Window:

Initial Review:

Decision Timeline:

Extension Requests:

Service Proof:

Risks of Incomplete or Incorrect Requests

Common Preparation Mistakes to Avoid

Comparing eSignature Providers for Submitting Requests

Frequently Asked Questions and Troubleshooting

Explore Templates

State of New York
WORKERS' COMPENSATION BOARD