Form OC-400 at a glance
What it is: Form OC-400 is the State of New York Workers' Compensation Board's Notice of Retainer and Appearance and Notice of Substitution and Appearance.
Who signs: Sign the Claimant's Signature (Ink Only - Use Blue Ink If Possible) and enter the Date, or check Electronic Signature. Sign the Signature of Attorney/Representative and enter the Date, or check Electronic Signature.
This form may be used by an original, substituted or additional attorney or representative.
A filled-in Form OC-400 example: an attorney files a first retainer
How to fill out Form OC-400, box by box
Check one notice
Check one: Notice of Retainer and Appearance, Notice of Substitution and Appearance, or Notice of Retainer and Appearance - Appellate Attorney.
For substitutions, item C must also be completed.
Check the appropriate box on top of the form.
Case, claimant, employer, insurer and attorney
Enter the WCB Case No., Social Security No. and Date of Injury/Illness, Paid Family Leave ("PFL") Start Date, or PFL Discrimination Complaint Date.
Enter the Name and Address of the Claimant, the Employer, the Insurer and the Attorney or Representative.
Enter the Telephone No. of Atty/Rep. and the Representative's ID No.
Employer for a volunteer benefit law claim
If claim is made under the Volunteer Firefighters' Benefit Law or the Volunteer Ambulance Workers' Benefit Law, show as EMPLOYER the liable political subdivision and enter "X" in the appropriate box.
Interpreter Required at Hearing
If an interpreter is required at the hearing, write the language under Specify Language.
A. Claimant complete this section
Check one: Please take notice that I have retained the firm/individual to represent me in all proceedings concerning my claim.
Please take notice that I have retained the firm/individual to represent me in my appeal to the Supreme Court, Appellate Division, Third Department, or the Court of Appeals.
Please take notice that in place of the blank line I have retained the named firm/individual to represent and appear for me in all proceedings concerning my claim.
Check the law your claim is under: Workers' Compensation Law, Section 120/241 WCL - Discharge or Discrimination Complaint, Disability Benefits Law, Volunteer Ambulance Workers' Benefit Law, Volunteer Firefighter's Benefit Law or Paid Family Leave Law.
You authorize the attorney/representative to request and obtain copies of any necessary medical records connected with the Workers' Compensation Board (WCB) case, and consent to the transmittal of all medical reports in this case from your health provider(s) to your attorney/representative.
If you attach a fully executed Form OC-110A (Claimant's Authorization to Disclose Workers' Compensation Records), list by number the workers' compensation case file(s) maintained by the NYS WCB.
B. Attorney/Representative complete this section
By completing B, you agree to represent the claimant in compliance with the Law and Rules and Regulations promulgated thereunder and notice your retention in the case. The only fees to be paid in this case are those fixed by the WC Law Judge, the Board, the Conciliator or designated employee of the Chair.
Check one: An Attorney at Law, A Licensed Representative with Fee--License No., or A Licensed Representative without Fee--License No.
Attorney or representative who is to appear, if other than yourself
If the attorney or representative who is to appear is other than yourself, enter the Name, Address, Tel.No. and R No.; the one named will appear in this case for one of: Next hearing only, Set period of time to, Until further notice (Unless revoked).
All notices, decisions and other documents should be sent to: both attorney/representative Firms, just the attorney/representative I retained, or just the attorney/representative named in Part B. Fees, if any should be made payable to: the attorney/representative I retained, the attorney/representative named in Part B or both attorney/representative firms.
C. For substitution only
For substitution only, complete this section: a copy of this notice of substitution was served on the day of, 20, on the Name of Former Attorney or Representative and Address.
Under (b) (1), an attorney or licensed representative, substituted for a former attorney or licensed representative, shall immediately upon being retained serve the former attorney or licensed representative with a copy of the notice of substitution.
D. Request and notice to health provider
Pursuant to Section 13(f) of the Workers' Compensation Law, please transmit copies of all your medical reports to me as the claimant's representative. Sign as the Attorney or Representative appearing for claimant. A photocopy of this notice shall be deemed as effective as an original.
E. Certification of transmittal of this notice
You certify that a copy of this notice was transmitted to the insurance carrier, self-insured employer or employer named as required by law; sign as Attorney or Representative and enter the Date.
More rules for Form OC-400
Send a copy of this form to all of the claimant's health providers, if applicable.
A copy of this form must be sent to the workers' compensation insurance carrier, self-insured employer or employer.
If your situation is different
Immediately upon being retained
Under Section 300.17, an attorney or licensed representative shall file a notice of retainer and appearance, and, when appropriate, a notice of substitution, in the format prescribed by the chair, immediately upon being retained. NYS Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205. Customer Service: (877) 632-4996.
You withdraw from representation of a claimant
Under (b) (2), an attorney or licensed representative may withdraw from representation of a claimant when: (i) a notice of substitution has been filed; or (ii) a withdrawal of representation completed in the format prescribed by the Chair has been filed and approved by a Workers' Compensation Law Judge or conciliator.
Failure to obtain the approval of a Workers' Compensation Law Judge or conciliator prior to ceasing representation of a claimant, when a notice of substitution has not been filed, will constitute the basis of a referral for a violation of 22 NYCRR, Part 1200.0, Rules of Professional Conduct, Rule 1.16 for an attorney, and may be the basis for license revocation of a licensed representative.
The claimant has terminated your retainer
Whenever an attorney or licensed representative is notified, by notice of substitution or otherwise, that the claimant has terminated his or her retainer, the attorney or licensed representative, in each instance where a fee is requested for services rendered for which no previous fee has been approved, shall file an application for such final fee in the format prescribed by the Chair, within 30 days of the filing of the notice of substitution.
Common questions about Form OC-400
Are there fees?
An attorney or licensed representative shall file an application in the format prescribed by the Chair in each instance where a fee is requested pursuant to sections 24 and 24-a of the Workers' Compensation Law, except that where the fee requested is not more than $1000, the attorney or licensed representative may, in lieu of such written application, make an oral statement on the record setting forth the calculation used to determine the fee and certifying that the amount is in accordance with subparagraph (2) of Section 24 of the Workers' Compensation Law. (checked November 3, 2026) The Board may require an application in the format prescribed by the Chair for a fee of $1000 or less. (checked November 3, 2026)
Is there a penalty?
Any person who knowingly and willfully obtains workers' compensation records which contain individually identifiable information under false pretenses or otherwise violates Workers' Compensation Law Section 110-a shall be guilty of a Class A misdemeanor and shall be subject upon conviction to a fine of not more than one thousand dollars. (checked November 3, 2026)
Sources
[1] Form OC-400 (1-23), Notice of Retainer and Appearance, New York State Workers' Compensation Board (the Official source link on this page).