Fill and Sign the Workers Compensation Board Yelp Form

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 5. District Office Where Case is Pending 1. W.C.B. Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury Address to which notices should be sent (Give Number and Street, City, State, and Zip Code) Name Social Security No. Apt. No. 6. InjuredPerson 7. Employer 9. Carrier Atty/Rep. I.D. No. if any. 9. Attorney orRepresentative R 10. WILL THIS BE THE FIRST HEARING IN THIS CASE? , if claimant's address shown above is new. Check here 11. - Reason for This Request Claimant not working and not receiving Workers' Compensation. Carrier unilaterally reduced/suspended payments W.C. Law Judge Continued/Adjourned Case until Hearing overdue. Other (Specify): Print Name Telephone No. & Ext. Title For WCB Use Only Signed Dated Hearing Set This form may only be used to request a hearing before a W.C. Law Judge in an open case. BY Date C-89.3 (9-91) CK0444 10-97 I 100 Broadway State Office Building State Office Building 130 Main Street W. 175 Fulton Avenue Menands 935 James Street 44 Hawley Street 1 80 Livingston Street 1 25 Main Street ROCHESTER 14614 HEMPSTEAD 11550 ALBANY 12241 SYRACUSE13203 BINGHAMTON 13901 BROOKLYN 11248 BUFFALO 14203 (716) 238-8300 (516) 560-7700 (51 8) 474-6674 (315) 423-2932 (607) 721-8356 (718) 802-6600 (71 6) 847-3158 YES NO