Form Ph 16 2 – Fill Out and Use This PDF

The statement is submitted by (check one): the claimant's legal representative or the employer or workers' compensation insurance carrier.

Enter the WCB Case Number, the Date of Injury/Illness, the Carrier Case Number and the Carrier Code No.

Enter the Claimant, Employer, Carrier and Other Parties-in-Interest.

Provide a brief summary of the claim. Give the theory of the case with statutory and, if appropriate, case citations.

2a. Carrier/Self-Insured Employer Defenses: [carrier/self-insurer only] List all the defenses that carrier is raising along with an offer of proof for each defense raised. If the carrier is raising an allegation that claimant has not presented prima facie medical evidence, please indicate and provide a basis for such challenge.

Did the injury occur while the claimant was working in the construction industry as defined in the New York State Construction Industry Fair Play Act (Labor Law § 861-B)? Did the injury occur while the claimant was driving in the commercial goods transportation industry as defined in the New York State Commercial Goods Transportation Industry Fair Play Act (Labor Law § 862-B)? Check No or Yes for each.

If Yes to either of them, does the employer continue to raise the issue of Employer-Employee relationship? If Yes, please provide the Employer Name, Employer Address and Federal Tax ID #.

Enter the Employer Name, the Number and Street Employer Address, the Zip Code, State and City, and the Federal Tax ID #. The Tax ID # is the (check one): SSN or EIN.

Provide the names of additional parties, if any, necessary to the adjudication of the claim, and explain why they are necessary.

Provide the names, addresses, and employers, if known, of all lay witnesses, including claimant, you intend to present, along with a statement as to the nature of their testimony and the estimated time needed for testimony. Please note: lay witness testimony will be taken at the first expedited hearing following the pre-hearing conference.

Provide the names of any medical witnesses you intend to cross-examine, if known, whether you wish the cross-examination by deposition or at a hearing, and the estimated time needed for the cross-examination. Please note: depositions shall be conducted and transcripts filed with the Board no more than 55 days from the pre-hearing conference.

List and attach all reports, forms, or documents necessary to the resolution of the claim that have not already been submitted to the Board's electronic case file.

All attachments to the form must be submitted to the Board with this form if they are not already in the electronic case folder. Do not submit attachments that are already in the Board's file.

Has all discovery relative to the threshold issues of compensability been completed or will be completed by the pre-hearing conference? If no, detail what further discovery is necessary and why it will not be completed prior to the pre-hearing conference.

Has the claimant been examined by the insurance carrier's doctor? If yes, when? Please note: IME reports on the threshold issue of causal relationship shall be served and filed three days prior to the initial expedited hearing or the first hearing in accordance with 300.33(f)(12).

Does the carrier request that the claimant provide a broader release for medical records than that provided on the Limited Release of Health Information (Form C-3.3)? If yes, the carrier or its legal representative must file with the Board along with this conference statement an affidavit or affirmation setting forth the relevance of the medical records sought.

What is the proposed average weekly wage if the claim is found compensable? On what evidence is this based? (If not already filed, carrier must attach Form C-240.)

What is the claimant's current work status? (If not already filed, carrier must attach Form C-11, if appropriate.)

Has a good faith effort been made to settle or otherwise resolve the claim for benefits? No Yes

Sign on the Signature of Person Preparing Form line, and enter the Date, the Print Name and the Title.

For Claimants Without Legal Representation: A claimant who has not retained a legal representative is not required to fill out this form.

If a legal representative is retained by the claimant, and ten or more days remain before the pre-hearing conference, the legal representative is required to fill out this form.

If the claimant retains a representative with less than 10 days remaining until the pre-hearing conference, the insurance carrier or employer will be able to adjourn the proceedings, which will result in a delay in a potential award of compensation and medical benefits.

Failure by the insurance carrier to timely serve upon all other parties and file with the Board the pre-hearing conference statement, or the filing by the insurance carrier of a materially incomplete statement shall result in a waiver of defenses to the claim.

Failure to list a witness on, or to include a copy of any document not in the ECF with the pre-hearing conference statement, which the insurance carrier had in its possession or could reasonably have obtained, shall constitute a waiver of the right to call such witness or introduce such document in the case.

There shall be no waiver if the workers' compensation law judge finds, based on the affidavit of the insurance carrier's legal representative (or if the insurance carrier does not have a legal representative, by the insurance carrier) that the conduct at issue was due to good cause and the insurance carrier exercised good faith and due diligence.

The legal fee of the claimant's legal representative shall be subject to a mandatory, substantial reduction for any of the following: 1) Failure to timely serve on all parties and file with the Board the claimant's pre-hearing conference statement 2) Filing of a materially incomplete pre-hearing conference statement 3) Failure to list a witness, who subsequently testifies, on the pre-hearing conference statement 4) Failure to include on the pre-hearing conference statement a copy of any document not in the Board's electronic file, which the claimant had in his or her possession or could reasonably have obtained, if such document is used by claimant's legal representative in seeking to establish the claim.

This statement must be completely filled out separately by claimant's representative and the employer or carrier, and each party must file with the Board and serve the completed statement on all parties no later than ten days before the date of the pre-hearing conference.

Reports should be sent directly to the Workers' Compensation Board at: NYS Workers' Compensation Board Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205. Customer Service Toll-Free Line: 877-632-4996. Statewide Fax Line: 877-533-0337. PH-16.2.0 (10-18) www.wcb.ny.gov